lili 









HHHI 









VBHHl 

'IPS 

K : 41111 






vv.-: :■•.-.■ :■'■■ 






■ ■■,- ■■•■ - 

;■■■:■:"■ i -" : / M ' ■ v i 

Hit 





Class , "^ ^ ^£ ) 
Book 3a% 

Copyright N° 



COPYRIGHT DEPOSIT. 



ESTABLISHED 1864 



SUBSCRIPTION, $2.00 



ARCHIVES 

OF 




A„M0NTHLY JOURNAL 

OEVOTED TO THE 

Diseases^of Infantsf and Children 



WALTER 


LESTER 


CARR, M.D., Editoi 




L, E. LA FETRA, M.D., Associate Editor 






■ collaborators: 




'X.Jacobi, M.D., 


;N«w York 


T. M. Rotch, M.D.0. 


[Boston 


V.P. Girney, M.D.,- 


Tf 


F. Cordon Morrill, M.D. 


7 ^ " \ 


L. EmmettHolt, M.D., 


Wm. Osler, M.D., 


Baltimore. 


Joseph E. Winters, M.D.,\ 


«• 




W. D. Booker, M.D.,, ' 


" 1 


W. P. Northrup. M.D., 


r 




S. S. Adams, M.D., 


■Washington' 


Ployo M. Crandall, M.D., 






Geo. N. Acker, M.D., 


) Buffalo j 


Auoustus Caille, M.D.; 


i" 




Irvino M. Snow, M.D., y 
Samuel W. Kelley, M.D.J 


Henry D. Chapin, M.D., 


[" 




Cleveland 


A. SlIBERT, M.D., 


"i 


A. V anoer Veir, M.D., 


Albany 


Francis Huier, M.D., 


l"i 


J. Park West, M.D., 


. Bellaiiei 


■Hbnry Koplik, M.D., 


.'"! 


Frank P. Norrury, M.D., 


St. Louis ' 


Rowland G. Freeman-, M.O. 


t ! ' 


W. A. Edwards, M.D., 


San Diego 


David Bovaird, Jr., M.D., 


■> 


James F. Goodhart, M.D. 


, London) 
f " } 


Louis Starr, M.D., 


Philadelphia 


F.ustaci Smith, M.D., 


Edward P. Davis, M.D., 


" 


James Finlayson, M.D., 


Glasgow! 


Edwin B. Graham, M.D., 


•■: 


J. W. Ballantyne, M.D., 


Edinburgh 1 


J. P. Croeer Griffith, M.D., " 


James Carmichael, M.D., 




W. S. Christopher, M.D;, 


Chicago 


John Thomson, JM.D., 


«• 


A! C Cotton, M.D.,. 


f- « \ 


Henry Ashry, M.D., 


f Manchester] 


F. Forchhbimer, M.D., 


Cincinnati 


G. A. Wrioht, M.D., 


" 


B. K. Rachford, M.D.,i 


" 


A. D. Blacka'der, M.D., 


i. Montreal 


, C G. JENNINGS, M.D., 


, Detroit 


Ioaquui L. Duenas, M.D. 


Havana 


SUBSCRIPTION'. 12 00 A YEAR IN ADVANCE. 


(ENQLAND, IOi 6d.) SlNOLB COPY. 20 CENTS 



NEW YORK: 
B. TREAT & CO., Publishers, 241-243 West" 23d Street 

LONDON. 48 Old Bailey, E.C 

a. Copyright, ««o«, by E. B. Treat A Cot 1 



NEUROTIC DISORDERS 

of 

CHILDHOOD 

INCLUDING a STUDY of AUTO and INTESTINAL 
INTOXICATIONS, CHRONIC ANAEMIA, 
FEVER, ECLAMPSIA, EPILEPSY, 
MIGRAINE, CHOREA, HYS- 
TERIA, ASTHMA, 
ETC. 

By 

B. K. RACHFORD, M. D. 

Professor of Diseases of Children, Medi- 
cal College of Ohio, University of Cin- 
cinnati. Pediatrist to the Cincinnati, 
Good Samaritan and Jewish Hospitals. 
Member of American Pediatric Society, 
Association of American Physicians, etc 



NEW YORK 

E. B. TREAT & COMPANY 

241-243 West 23d Street 

1905 



)Pies rfeeatvea 

OCT. 27 J9Q5 

Gopyrignt cne-j/ 



Copyright 

By B. K. RACHFORD 

1905 



PRESS OF 

ARCHIVES OF PEDIATRICS 



^ 



^ b 



^ 



\ 



PREFACE 

In 1893-94 I published a series of papers in the Ar- 
chives of Pediatrics entitled " Some Physiological Fac- 
tors of the Neuroses of Childhood." 

In these papers I made an effort to study the physi- 
ological peculiarities of the immature nervous systems of 
infants and children, and to note the all-important bear- 
ing which these peculiarities had in producing and in giv- 
ing individuality to the neuroses of childhood. 

It is a well-known fact that infants and children are 
especially predisposed to serious and complicated nerv- 
ous disorders, and that this class of diseases has been 
very little understood by the general practitioner, and 
has, in fact, not been a matter of special study by 
neurologists. 

For these reasons I decided to revise the papers 
previously published in the Archives of Pediatrics and 
make of them the nucleus of a book on the Neurotic Dis- 
orders of Childhood. 

Part I. of this book contains these revised papers, with 
the addition of chapters on " Gastro-Intestinal Toxae- 
mia," " Auto-Intoxications " and " Chronic Systemic 
Bacterial Toxaemias." 

Part II. of this book deals with the individual neuroses. 
Here I have attempted a careful study of the many 
neurotic disorders of childhood, and have endeavored to 



PREFACE 

so present the etiology, symptomatology, and treatment 
of these diseases that the student of medicine and the 
general practitioner will not only be able to better com- 
prehend these common and little understood diseases, 
but will also be able to apply successful lines of treat- 

ment B. K. Rachford, M.D. 

Cincinnati, Ohio, September, 1905. 



CONTENTS 

PART I 
CHAPTER I 

PAGB 

NORMAL FUNCTIONS OF NERVE CELLS— Generation, 

Discharge and Inhibition of Nerve Energy .... 13 

CHAPTER II 

PHYSIOLOGICAL PECULIARITIES OF THE NERV- 
OUS SYSTEM DURING INFANCY AND CHILD- 
HOOD 21 

CHAPTER III 

PHYSIOLOGICAL FACTORS OF THE HIGH FEVERS 
AND THE VARIABLE TEMPERATURES OF 
CHILDHOOD 31 

CHAPTER IV 

GASTRO-INTESTINAL TOXAEMIA— A Cause of Fever— 
Nervous Symptoms — Convulsions 45 

CHAPTER V 

AUTO-INTOXICATIONS— Acid Intoxications Most Im- 
portant — Thyroid Intoxication in Rapidly Growing 
Children Produces Nervous Symptoms — Biliary Toxae- 
mia May Produce Severe Cerebral Symptoms .... 59 

CHAPTER VI 

CHRONIC SYSTEMIC BACTERIAL TOXEMIAS— 
Lymph Node Tuberculosis — Rheumatism, Malaria, 
Hereditary Syphilis, Important Factors in Producing 
Nervous Syndromes 85 

7 



8 CONTENTS 

CHAPTER VII 

FAGS 

CHRONIC ANEMIA— Fat, Calcium, Haemoglobin, and 

Oxygen Starvation Produce Nervous Symptoms ... 93 

CHAPTER VIII 

REFLEX IRRITATION— An Important Cause of Nervous 
Diseases — Spinal Irritability — Fatigue Changes in 
Nerve Cells 104 

CHAPTER IX 

EXCESSIVE NERVE ACTIVITY— Brain Work and Nerve 
Excitement Causes of Neurotic Disorders — Early Pre- 
cocity an Abnormal Condition 112 



PART II 

CHAPTER X 

FEVER — Heredity, Malnutrition, and Bacterial Products 

Causes of Fever in Childhood— Treatment 123 

CHAPTER XI 

ECLAMPSIA IN INFANTS AND CHILDREN— Predispos- 
ing and Exciting Causes — Heredity, Rachitis, Chronic 
Reflex Irritation, Bacterial Toxemia, and Auto-In- 
toxication — Treatment 136 

CHAPTER XII 

LARYNGISMUS STRIDULUS— Important Factors and 
Symptoms — Rachitis — Gastro-Intestinal Disorders — 
Spasm of the Glottis — The Underlying Causes to be 
Treated • • . . 158 

CHAPTER XIII 

TETANY— Its Etiological Factors and Characteristic 
Symptoms are Rachitis, Gastro-Intestinal Toxemia, 
and Carpo-Pedal Spasms * 165 



PAGE 



CONTENTS 
CHAPTER XIV 

ENURESIS— A True Neuroses— Various Causes and Treat- 
ment 175 

CHAPTER XV 

MIGRAINE — Common in the Young Adult — Traceable to 
Heredity, Constipation, and Auto-Intoxications — Symp- 
toms — Treatment 192 

CHAPTER XVI 

RECURRENT VOMITING— Related to Migraine— Has 

Similar Etiological Factors — Diagnosis — Treatment . 217 

CHAPTER XVII 

EPILEPSY — Classified as Developmental, Organic, and 
Toxic Epilepsy — Due to Various Causes — Symptoms — 
Treatment 235 

CHAPTER XVIII 

RECURRENT CORYZA— A Condition Allied to Migraine 
and Recurrent Vomiting, Caused by Auto or Intestinal 
Toxines — Symptoms — Treatment 261 

CHAPTER XIX 

A CLINICAL STUDY OF CASES— Illustrating the Kin- 
ship of Recurrent Vomiting, Recurrent Coryza, Toxic 
Epilepsy, and Migraine 268 

CHAPTER XX 

CHOREA — A Syndrone Produced by a Variety of Causes, 
Notably Rheumatism, Heart Disease, Anaemia, Tuber- 
culosis and Chronic Malaria — Symptoms — Treatment 302 

CHAPTER XXI 

HYSTERIA — Its Various Etiological Factors and Manifes- 
tations — Suggestion is Most Important in its Cure . . 328 



10 CONTENTS 

CHAPTER XXII 

PAGE 

HEADACHES AND EARACHE, Common in Childhood- 
Causes — In Treatment Remove the Gastro-Intestinal 
and Reflex Irritations 355 

CHAPTER XXIII 

ASTHMA— May be Reflex or Toxic— Remedies for its Re- 
lief — During Intervals all Diseases of the Nose, 
Throat and Respiratory Passages Should be Treated— 
Change of Climate Advisable 366 

CHAPTER XXIV 

DISORDERS OF SLEEP— Insomnia— Night-Terrors of 
Different Types — Due to Various Causes — Value of 
Tonic and Sedative Medication 378 

CHAPTER XXV 

NYSTAGMUS, and Associated Movements of the Head and 
Eyes in Infants 395 

CHAPTER XXVI 

HABIT SPASM— This Syndrone Occurs in Highly Neu- 
rotic Children — Mechanical Restraint Important in 
Treatment of Habit Neurosis 402 

CHAPTER XXVII 

PICA, OR DIRT-EATING in Children— Causes— Treat- 
ment 4 X 7 



PART I 



Neurotic Disorders of Childhood 

CHAPTER I 

NORMAL FUNCTIONS OF NERVE CELLS 

The term " neuroses of childhood " is used to cover 
all local and general nervous disorders which do not 
depend on known local pathological lesions of the nerv- 
ous system. This definition of the term neuroses does not 
imply that these diseases have an entirely unknown 
pathology, but that they cannot be morphologically 
classified. In these diseases we know more of the symp- 
toms than we do of the lesions, more of the effect than 
we do of the cause, more of the disordered functions of 
nerve cells than we do of the widely varying patho- 
logical conditions which produce these disordered func- 
tions, and these are the reasons why these diseases are 
incorrectly called functional nervous diseases. 

The first requisite to the study of perversions in the 
functions of nerve cells should be a knowledge of the 
normal functions of nerve cells. For this reason the 
following preliminary physiological outline is introduced. 

Nerve cells have three important functions, viz., to 
generate, to discharge, and to inhibit energy. 

The highest function of the nerve cell is to generate 
energy. By this it is meant that the cell transforms 
and appropriates existing energy. The amount of ex- 
isting energy is constant; the cell does not and cannot 



14 NEUROTIC DISORDERS OF CHILDHOOD 

originate energy, but in the chemical metabolism neces- 
sary to the life of the cell force is developed, which is 
transformed into that form of nerve energy which is 
the special function of the individual cell (Professor J. 
Gad — personal communication), and this nerve energy 
is stored up to be discharged in the exercise of the 
cell's peculiar function. From this it would follow that 
the generation of nerve force would be directly dependent 
on the healthful chemical metabolism of the nerve cell; 
but it does not follow that the amount of energy thus 
developed would always be commensurable with the 
physical waste or the chemical metabolism going on in 
the cell. This disproportion between cell activity and 
the amount of force developed is especially noticeable 
in the immature nerve cells of the child. A most marked 
example of the slight amount of energy developed by 
the cell activity of immature cells may be noted in the 
cortical cells of the brain of the infant and the brain 
of the unintelligent adult. In such brains the cortical 
cells concerned in the development of mental energy 
have going on within them an active chemical metab- 
olism with the development of very little mental energy, 
and this failure of chemical metabolism to develop com- 
mensurate mental energy is due to the incomplete func- 
tional development of these cells. The same amount 
of force may be developed, but the cell has not the power 
of converting this force into mental energy. Of all the 
cells in the body, the cell that develops mental energy 
is the slowest in reaching the degree of functional per- 
fection for which it is destined, and it does so only after 
a judicious training, in the exercise of its peculiar func- 



NORMAL FUNCTIONS OF NERVE CELLS 1 5 

tion, throughout a long period of about twenty-three 
years. 

The functional development of the motor cell is much 
more rapid, and during this development the dispropor- 
tion between the amount of cell activity and force pro- 
duced is not so great as in the mental cell, but neverthe- 
less it may be stated as a fact true for all nerve cells, 
that the amount of energy which a cell is capable of gen- 
erating will depend on the degree of functional develop- 
ment which the* cell has attained. But these facts, con- 
cerning the difference in the amount of cell energy 
developed by different cells under the same conditions, 
do not in any way modify the force of the statement made 
above, that nerve energy is directly dependent on the 
chemical metabolism of the nerve cell. It will therefore 
be permissible for us to say that, other conditions being 
the same, the amount of energy developed by a nerve 
cell will directly depend on the amount of healthful 
chemical metabolism going on within it. This point in 
the physiology of the development of cell energy is very 
important, since upon it rests the conclusion that insuf- 
ficient nourishment will diminish the capacity of the 
nerve cell for the generation of energy. The maximum 
amount of energy will, therefore, be found stored in 
the well-nourished cell and the minimum amount of 
energy in the starved cell. We shall see later that this 
statement, which has important clinical bearing, can be 
strongly supported by experimental evidence. 

Discharge of nervous energy is a function of the nerve 
cell only second in importance to the generation of 
energy. The more or less constant discharge of force is 



1 6 NEUROTIC DISORDERS OF CHILDHOOD 

an automatic function of the nerve cell, and this uncon- 
scious discharge of nerve energy is the regulating func- 
tion that controls the whole body mechanism. As an 
example of this automatic discharge of nerve force, one 
may cite the influence of the central nervous system over 
involuntary muscular tissue, whereby the "muscular 
tone " of involuntary muscles is maintained. The vaso- 
motor center in the medulla oblongata has such an in- 
fluence on the muscular coats of blood vessels as to keep 
them in a state of normal contraction best adapted for 
the purposes which they serve. This vascular tone re- 
mains much the same at all times, except when the func- 
tions of the center are perverted by some change in the 
metabolism of the cells, or by influences acting on the 
center either directly or in a reflex manner. But possibly 
of even greater importance to us, in this study, is the 
tonic influence of the spinal motor cells on the sphincter 
muscles of the anus and the bladder, which are dependent 
on the spinal cord for their normal muscular tone. The 
" muscular tone " of these sphincter muscles is easily 
disturbed by reflex stimulation, producing on the one 
hand spasmodic stricture and on the other incontinence. 
The muscular tone of the skeletal muscles is likewise said 
to be maintained by an automatic discharge of nerve 
force, and a perversion of this function may in the same 
manner produce complete relaxation, or irregular spas- 
modic contractions of these muscles. These examples 
on the part of the muscles are sufficient to illustrate 
how nerve cells, by the automatic discharge of nerve 
force, regulate the whole body mechanism. It would 
be of no value for us to discuss whether this more or 



NORMAL FUNCTIONS OF NERVE CELLS \J 

less constant discharge of nerve force is purely an auto- 
matic function of the cell, or whether it is due to uncon- 
scious afferent impulses producing a reflex discharge of 
force. It is sufficient for us to know that these phenomena 
exist, and it is a matter of words whether we speak of 
them as automatic or as reflex. 

Nerve force may also be discharged voluntarily. This 
power of willing the discharge of nerve impulses re- 
sides in the cortical cells of the cerebrum. The influ- 
ence of the will over the discharge of force, by the spinal 
motor cells, is a physiological fact of great clinical im- 
portance in the study of the neuroses of childhood. 

Thirdly, and lastly, and most important of all, so far 
as our present study is concerned, nerve force may be 
discharged reflexly. This reflex discharge of force occurs 
when nerve cells are acted on by outside stimuli. If the 
stimulus be mild, the reflex discharge of energy from the 
normal motor cells of the cord occurs only through 
the paths of least resistance, viz., the efferent nerves in 
the same plane, and on the same side, as the nerve fiber 
that carried the afferent stimulus; but if the stimulus 
be more severe the reflex discharge of force will also 
occur in the same plane, but on both sides of the cord. 
We shall see later how these simple laws of reflex action 
have little control over the reflex discharge of nerve force 
under certain pathological conditions. 

Inhibition of nervous energy is the third important 
function of the nerve cell. Certain cells throughout the 
central nervous system have the power of inhibiting 
energy discharged by other cells, and it is also possible 
that some cells of high functional development may have 



1 8 NEUROTIC DISORDERS OF CHILDHOOD 

the power of inhibiting their own energy. But however 
this may be, it is a well-established fact that inhibition 
does exist, and that this power of inhibiting nervous 
energy may be either voluntary or involuntary. Vol- 
untary inhibition of mental and motor force is a func- 
tion peculiar to the cells of the cerebral cortex, but invol- 
untary inhibition of nerve force is a function of cells 
everywhere distributed throughout the central nervous 
system; but the higher centers are always the predomi- 
nating centers when the nervous system is intact. The 
spinal cord contains cells, or collections of cells (centers), 
which are capable of being excited reflexly, so as to give 
motor expression to sensory stimulants, and inhibition 
can best be understood by studying the inhibitory influ- 
ence of the higher centers on spinal reflex acts. The 
spinal reflex centers can act quite independently of higher 
centers. Gad demonstrated that after section of the 
spinal cord at any point the centers below the section are 
still active and capable of translating sensory impressions 
into motor acts. But this absolute autonomy of the 
spinal reflex centers does not exist when the spinal cord 
is in normal communication with the brain; then the 
reflex centers in the cord are more or less under control 
of other centers higher up in the cord (the medulla 
oblongata and the brain). These centers may influ- 
ence the lower spinal centers, not only in causing them 
to discharge force, as we have above noted, but also 
in inhibiting their reflex acts, which are discharged from 
any cause whatsoever. Some of the inhibitory influ- 
ences coming from the brain are voluntary, and probably 
originate in the cells of the cerebral cortex; for 



NORMAL FUNCTIONS OF NERVE CELLS I9 

example, we can by voluntary inhibition control the 
urinary bladder reflexes and prevent urination even when 
the micturition center, in the lumbar cord, is strongly 
stimulated ; and again there are spinal reflexes over which 
voluntary inhibition has no control, as, for example, 
erection, ejaculation, movement of the iris. 

Of even more importance to us in the study of the 
neuroses of childhood are the involuntary inhibitory cen- 
ters which are distributed throughout the central nerv- 
ous system. They are found in the brain, the medulla 
oblongata, and the spinal cord, and without voluntary 
effort or apparent reflex stimulation these centers seem 
to exert a constant inhibitory influence on the lower 
spinal centers. Setchenow's inhibitory center, in the 
medulla oblongata, is an example of similar centers which 
we have reason to believe exist in the large ganglia at 
the base of the brain. The inhibitory influence of this 
center on spinal reflex acts has been quite satisfactorily 
demonstrated. It is also easy to demonstrate, in a brain- 
less frog, that stimulation of the sciatic nerve will inhibit 
spinal reflex acts. It is clear, therefore, that spinal inhi- 
bition may be brought about by other impulses than those 
that come from predominating centers in the brain and 
medulla oblongata; that is to say, by impulses which are 
not in themselves of a specific inhibitory nature, but 
originate in the peripheral stimulation of sensory nerves. 
But it is not necessary for me to narrate experiments 
bearing on the subject of inhibitor! of nerve force, for 
such experiments are so satisfactorily detailed in the 
physiologies that I need here only say that experimental 
physiology teaches us to believe that there are cells, every- 



20 NEUROTIC DISORDERS OF CHILDHOOD 

where distributed throughout the central nervous sys- 
tem, which have the power of inhibiting nervous energy. 
It matters little to us in the present study whether this 
inhibition is always the special function of certain cells 
or whether it may also be the function of the nucleus 
of the cell that discharges the energy ; but it is important 
for us to know that inhibition exists both for mental and 
motor acts, and we will see later why a clear understand- 
ing of the influences that control and disturb inhibition 
is of the utmost importance to us in the study of the 
neuroses of childhood. If kept in mind, the above out- 
line of the normal functions of the mature nerve cell 
will materially assist in the study of the functional 
peculiarities that are manifested by the immature cells of 
the rapidly developing nervous system of the child. 



CHAPTER II 

PHYSIOLOGICAL PECULIARITIES OF THE NERVOUS 
SYSTEM DURING INFANCY AND CHILDHOOD 

We have some knowledge of a few of the physio- 
logical peculiarities of the immature nervous system of 
the child that have a most important etiological import 
in the study of the neuroses of childhood, and it is my 
purpose here to outline such of these peculiarities as I 
believe to have a bearing on neurotic disease. 

In the young infant the dura mater is very closely ad- 
herent to the skull, and the blood vessels of the pia mater 
are so abundant and so fragile that hemorrhage into the 
subarachnoid space may result from causes which pro- 
duce high blood pressure. 
/ At birth the brain is morphologically and functionally 
the most immature of all the great organs of the body. 
From birth up to seven years of age it develops enor- 
mously in weight, in structure, and in function. At 
this time the brain has attained 90 per cent, of its maxi- 
mum weight (Boyd), and after this slowly increases in 
weight up to the age of eighteen; but increase of func- 
tion does not keep pace with increase of weight, — the 
brain of a child of eight is almost as large as the brain of 
an adult, — but, as Clouston aptly says, " the difference be- 
tween what the brain of a child of eight and the brain of 
a man of twenty-five can do and can resist is quite inde- 
scribable. The organ at these two periods might be- 

21 , 



22 NEUROTIC DISORDERS OE CHILDHOOD 

long to two different species of animals, so far as its 
essential qualities go." 

The chief structural deficiency at this time is in the 
cortex, and from this time on the increase in cortical 
matter is relatively greater. While the rapid increase 
in weight of the brain does not continue after the seventh 
year, the rapid increase in the brain's functional devel- 
opment goes on, and still continues, long after the brain 
at eighteen has reached its maximum weight. Clouston 
says : " The unique fact about the nerve cell is the ex- 
treme slowness with which it develops function after its 
full bulk has been attained. " " In this it differs from 
any and every other tissue." " We may say that after 
most of the nerve cells of the brain have attained their 
proper shape and full size, it takes them the enormous 
time of eighteen or nineteen years to attain such func- 
tional perfection as they are to arrive at." It is an 
important fact that should always be kept in mind that 
the entire nervous system, of the normal infant and child, 
is constantly undergoing structural and functional devel- 
opment, and that the structural development, so far as 
we are able to judge by our instruments of precision, is 
much more rapid than is the development of function. 
It is also a fact that even with normal children this de- 
velopment of structure and function does not always 
go on with the same rapidity, nor does it always follow 
a regular order in its development. It is quite within 
the limits of health that certain functions may be rapidly 
developed and that other functions may be unusually 
retarded in development. The innumerable conditions 
of heredity and environment have their influence on the 



PECULIARITIES OF THE NERVOUS SYSTEM 23 

nervous system of the child in developing and retarding 
both structure and function, and this interference with 
the order of development is not an abnormal condition 
if, within a reasonable time, the delayed functions reach 
a normal state of development. But it is not my pur- 
pose to enter deeply into this phase of my subject. I only 
wish to call attention to the following important facts : 

1. At birth the nervous system is structurally, but 
more especially functionally, immature. 

2. Throughout infancy and the earlier years of child- 
hood the brain normally undergoes rapid structural 
development. 

3. Throughout the entire period of infancy and child- 
hood the brain normally undergoes rapid functional 
development. 

4. Innumerable conditions of heredity and environ- 
ment have much to do with the rapidity and the order 
of development of the functions of the nervous system 
of the normal child, as well as with the failure and re- 
tardation of their development in the abnormal child. 

5. The metabolism in the normal immature nerve cell 
of the child must be rapid enough not only to supply 
the functional waste, but also to supply the material for 
the growth and development of cells. 

6. This structural instability of the functionally weak 
and immature nerve cell of the child makes it much more 
irritable and excitable than the stable mature nerve cell 
of the adult. 

With these general considerations of some of the func- 
tional peculiarities of the nervous system during child- 
hood, let us pass to the consideration of certain special 



24 NEUROTIC DISORDERS OF CHILDHOOD 

functions of the nervous system which are not the same 
in childhood as in adult life. 

The feeble inhibition of nerve energy is from a clinical 
standpoint the most important physiological peculiarity 
of the nervous system in infancy and childhood. The 
inhibitory function of the nerve cell is the last to be de- 
veloped. The cell first acquires the function of gen- 
erating energy, then the function of discharging energy, 
and lastly the function of inhibiting and coordinating 
energy. These functions of the cells are developed in 
the order in which they are needed. Until energy is 
generated there can be no. occasion for a discharging 
function, and until energy is discharged there can be no 
occasion for an inhibiting function. Feeble inhibition 
is therefore one of the physiological characteristics of 
the immature nervous system of infancy and childhood, 
and it plays a most important role as a predisposing fac- 
tor to the neuroses of childhood. Inhibition is very feeble 
in young animals, and becomes stronger as the animal 
grows older. The inhibitory function of cells is, there- 
fore, in this regard like the generating function — it 
gradually becomes stronger as the cells get older, up to 
the time when they reach their complete functional de- 
velopment. But it must be remembered that the inhibi- 
tory function of a cell is always developed later than that 
function of the cell which generates the force to be 
inhibited. In the normal order of things the function 
of inhibition should closely follow the development of the 
function which generates the force to be inhibited. 

The inhibitory mechanisms which control the discharge 
of nerve force that regulates such vital processes as the 



PECULIARITIES OF THE NERVOUS SYSTEM 25 

action of the heart and the lungs are fairly well developed 
at birth, while those that regulate reflex phenomena are 
slowly developed during infancy and early childhood, 
and voluntary inhibition of motor and mental force does 
not not find its complete development till childhood has 
passed. The late development of the function of inhi- 
bition is a fact of prime importance from a clinical stand- 
point, because this is the last function of the cell to de- 
velop, and is the one that is most likely to be still further 
retarded in development by unfavorable conditions of 
heredity and environment. It is therefore the abnor- 
mally feeble inhibition which occurs in the abnormal child 
that is such a potent factor in the production of neurotic 
disease in infancy and childhood. 

It is my belief that this functional immaturity of the 
inhibitory centers is most important in explaining the 
manner in which childhood acts as a predisposing cause 
of such neuroses as convulsions, epilepsy, hysteria, and 
incontinence of urine. 

It is evident that inhibition is most feeble at birth, and 
gradually becomes stronger as the child grows older. 
This is especially true of voluntary inhibition. At birth 
voluntary inhibition, if it exists at all, must be very fee- 
ble, and it gradually grows stronger as the higher func- 
tions of the brain are more and more developed. We 
have a good example of voluntary inhibition in the in- 
fluence of the will over urination. One wills to urinate, 
and the impulse passes down the cord to the lumbar cen- 
ter that presides over urination, and it is there trans- 
lated into the reflex act of micturition; or, on the other 
hand, one wills not to urinate, and the impulse travels 



26 NEUROTIC DISORDERS OF CHILDHOOD 

down the cord to the lumbar center, and the act of urina- 
tion is inhibited. 

But the functional immaturity of the involuntary 
inhibitory centers is of even more importance to us as 
clinicians than the voluntary; for these centers having 
most to do with coordinating and regulating spinal move- 
ments, the lack of inhibition on the part of these centers 
would make it possible for an overflow of spinal reflex 
movements to occur passing up and down the cord, and 
in this way predispose to such convulsive disorders as 
eclampsia, chorea, and epilepsy. As previously noted, 
the reflex discharge of energy from the spinal motor 
cells occurs normally through the paths of least resist- 
ance, that is to say, in the same plane and on the same 
side, or in the same plane and on the opposite side, of 
the cord from where the nerve fiber entered that carried 
the afferent stimulus. But if the resistance to the spread- 
ing of the reflexes up and down the cord be reduced, or if 
the exciting stimulus be increased, then we may have an 
overflow of energy up and down the cord, exciting gen- 
eral spinal reflex movements. As above stated, these 
spinal reflex movements are inhibited, and an " over- 
flow " of energy prevented by the action of involuntary 
inhibitory centers higher up in the cord (the medulla 
oblongata and the brain). The normally feeble inhibi- 
tion of infancy predisposes to an " overflow " of spinal 
reflexes, or, in other words, to convulsive disorders of 
all muscles operated through spinal motor nerves. It 
is also easy to understand how unfavorable circumstances 
of environment and heredity, having their greatest re- 
tarding influence on the development of the inhibitory 



PECULIARITIES OF THE NERVOUS SYSTEM 2J 

function of the immature nerve cells of the infant and 
child, would still further predispose to overflow of spinal 
reflexes, and in this way to convulsive disorders. By 
this overflow of energy we may have a large number of 
spinal reflex movements as the result of a single exciting 
stimulus. Extensive convulsive movements of almost 
the entire body may in this way be caused by some 
simple discharging stimulus. It is one of the functions 
of the reflex inhibiting mechanisms to prevent this over- 
flow, so that an impulse sent to one portion of the cord 
may not overflow and spread to other portions of the 
cord; but this mechanism being inefficient, incoordinated 
and spasmodic muscular movements occur. This over- 
flow of nerve force is not peculiar to spinal cells exhibit- 
ing motor energy, but it also occurs in the cortical 
cells exhibiting mental energy (insanity). An inhibi- 
tion against this overflow is quite as important in the 
brain cortex as in the spinal cord. 

It is of clinical importance that we should here note 
that both the reflex centers and the conducting fibers by 
which reflex movements overflow, spreading up or down 
the cord, are in the sensory tracts of the cord, for this 
gives us a partial explanation of how certain drugs, such 
as cimicifuga, the bromides, antipyrin, and gelsemium, 
by depressing the sensory tracts of the cord, can control 
reflex spinal movements. 

INCOMPLETE DEVELOPMENT OF PYRAMIDAL TRACTS 

It is a fact of very great physiological and pathologi- 
cal importance that the fibers of the pyramidal tracts 
are the latest to become myelinated. At birth they have 



28 NEUROTIC DISORDERS OF CHILDHOOD 

no myeline sheaths, and, until their myeline sheaths are 
developed, it is believed that impulses cannot be carried 
from the convulsive centers at the base of the brain to 
the spinal cord cells. It has been noted that electrical 
excitation of the cerebral motor cortex, in dogs, at birth 
is not followed by movements (of extremities, etc.) pre- 
sided over by spinal motor cells. This phenomenon was 
for a time explained on the supposition that the cerebral 
cortex is non-excitable in very young animals. This 
non-excitability of the motor cortex was thought to be 
due to a lack of development of these motor areas. While 
this hypothesis may serve as a partial explanation of 
the failure of spinal movements to respond to stimula- 
tion of the motor cortex, it is now known that on or 
about the tenth day of the life of the dog, when the 
pyramidal tracts have acquired their myeline sheaths, 
an excitation of the motor cortex will produce motion 
in muscles over which the spinal motor cells preside. The 
absence or partial development of the myeline sheaths of 
the fibers of the pyramidal tracts in very young animals 
may interfere, wholly or partially, with the lines of com- 
munication between the cerebral motor centers and the 
spinal motor cells. Day by day, as these myeline sheaths 
are developed, the cerebral and spinal motor cells are 
brought into closer communication, and very early in the 
life of the animal (ten days in the dog, and perhaps 
three or four months in the human infant), communica- 
tion may be said to be fairly well established; prior to 
this time the communications are imperfect. 

The above physiological facts may be offered in expla- 
nation of the comparative immunity which young infants 



PECULIARITIES OF THE NERVOUS SYSTEM 29 

enjoy from convulsive disorders during the first few 
months of their lives. At this time it is probable that 
the motor areas of the cortex are not sufficiently well 
developed to respond readily to stimulation. It is also 
probable that the reflex centers of the cord are not fully 
developed at this early period; but most important of 
all is the fact that in certain young animals, and probably 
also in the human infant, the incomplete functional devel- 
opment of the pyramidal tracts makes the communica- 
tion between the convulsive centers at the base of the 
brain and the spinal motor centers much more difficult 
than it is a few months later, when the myeline sheaths 
of the fibers of the pyramidal tracts are fully developed. 

Convulsive Centers. — The true convulsive centers are 
located at the base of the brain, and probably all general 
convulsions are produced by a discharge of nerve force 
from these centers through the pyramidal tracts into the 
motor cells of the spinal cord. 

The cortical motor centers are not true convulsive 
centers, but they are in such close touch with the con- 
vulsive centers at the base that any violent irritation of 
these cortical centers may produce general convulsions 
by causing a discharge of force from the basal convul- 
sive centers. General convulsions of cortical origin may 
begin with convulsive movements in a single member, 
such as an arm or leg, and these become general through 
the action of the convulsive centers. The localized con- 
vulsive movements which precede the general convul- 
sion may not only help to determine that the convulsion 
is cortical in its origin, but it also determines the portion 
of the cortex from which the irritation proceeds, — the 



30 NEUROTIC DISORDERS OF CHILDHOOD 

arm, leg, or face center, as the case may be. The motor 
fibers which pass directly from the motor areas of the 
cortex to the arm, leg, and face centers in the cord carry 
the impulses which produce the localized convulsive 
movements in these parts. At the same time, the same 
cortical irritation (the impulse possibly slightly delayed 
in transmission by the necessary relay of force) excites 
the basal convulsive centers to discharge their force into 
the cord, and a general convulsion follows very quickly 
the local convulsive movements. Localized convulsive 
movements followed by general convulsions always mean 
severe cortical irritation from some local organic condi- 
tion. Localized convulsive movements not followed by 
general convulsions also mean localized organic disease, 
if not of the nervous system itself, then in such a loca- 
tion as to impinge upon or irritate certain of the periph- 
eral nerves and ganglia. General convulsions, how- 
ever, not preceded or marked by localized convulsive 
movements, are in the great majority of instances toxic 
in their origin. Where strong predisposition exists, 
either from hereditary influences or constitutional dis- 
ease, general convulsions may be touched off by reflex 
causes. 

Another reason for the infrequency of the reflex neu- 
roses (including certain convulsive disorders) in the 
young infant is that the peripheral endings of the sen- 
sory nerves are not so perfectly developed in the early 
days of life as they are some months later. 

In the light of the above physiological facts the feeble 
inhibition of early infancy is not so potent a factor in 
producing disease as it is a little later on, when inhibi- 



PECULIARITIES OF THE NERVOUS SYSTEM 3 1 

tion is found not to have kept pace with the development 
of other functions of nerve tissue. The reflex centers 
of the cord and motor areas of the brain early in life 
take on the abnormal excitability of young nerve centers 
and are put in close communication by the functional 
development of the pyramidal tracts; but the inhibitory 
function of higher nerve centers over spinal cells and 
centers is very slow in reaching full development. In 
this way feeble inhibition, after the first few months 
of life, comes to play an important role as a predispos- 
ing factor to the neuroses of childhood. 

The non-excitability of reflex centers in the spinal cord 
of the young infant has yet another important bearing, 
since it is in great part responsible for the lack of tone 
of the sphincter muscles of the infant. I have pre- 
viously noted that the muscular tone of the sphincters 
was maintained by an automatic function of the central 
nervous system so closely analogous to reflex action 
that it seems a difference of name rather than of func- 
tion. Now these reflex or automatic functions of the 
cord are so immature, in the newly born, that there is 
a lack of tone of all sphincter muscles — that is to say, an 
absence of the normal amount of contraction which after- 
wards fits them for the purposes they are to serve, and 
which depends in great part upon the action of normal 
reflex centers in the cord. This lack of sensitiveness of 
the reflex centers of the cord in the infant is, in my 
opinion, a most important factor in producing the incon- 
tinence which is characteristic of infantile sphincters. 
The incontinence of infantile sphincters passes away with 
the functional development of the centers whose function 



32 NEUROTIC DISORDERS OF CHILDHOOD 

it is to maintain in them the normal amount of muscular 
tone that fits them for the purposes they are to serve. 
Abnormal conditions of heredity and environment may 
much delay the functional development of these centers, 
and for this reason a complete or partial incontinence 
may continue long after the period when it should nor- 
mally disappear. During this period, when involuntary 
inhibition is so feeble, voluntary inhibition is of great 
service in preventing, as it usually does, the diurnal 
incontinence. But at night, when the will is asleep, a 
minimum reflex will overcome the feeble involuntary 
inhibition and cause a relaxation of the sphincters. 
Besides this, any abnormal conditions of heredity or 
environment which increase the irritability of these reflex 
centers will also make it possible for slight reflex causes 
to disturb the " muscular tone " of sphincters, and cause 
either spasmodic stricture or incontinence. The patho- 
logical conditions, therefore, which produce feeble inhi- 
bition and excitable nerve centers are sufficient explana- 
tion for the not infrequent condition of incontinence of 
sphincters during childhood, and it is not necessary to 
invoke a cause which does not as a rule exist, viz., in- 
sufficient muscular development. 



CHAPTER III 

SOME PHYSIOLOGICAL FACTORS OF THE HIGH FEVERS AND 
THE VARIABLE TEMPERATURES OF CHILDHOOD. 

It is a well-known fact that children are more prone 
to fever than adults, and it is also well known that the 
temperature is more variable in the fevers of infancy 
and childhood than it is in the fevers of adults. Why 
this is so is a question which we now wish to study from 
a physiologic standpoint. But first let us clearly under- 
stand what we mean by the terms high temperature and 
fever. 

By high temperature is meant an increase of the body 
heat, whether it be due to increased heat production or 
diminished heat dissipation. When high temperature 
is due to increased heat production it is a symptom of 
fever, but when it is due to diminished heat dissipation 
it is not a symptom of fever. 

By fever is meant an abnormal increase of those tissue 
changes by which the normal heat of the body is pro- 
duced, that is to say, an abnormal increase of the chemic 
changes which result in disorganizing tissues and break- 
ing them up into carbonic acid, water, urea, and other 
products of retrograde metamorphosis. 

The fever process is characterized by a chain of symp- 
toms with which every clinician is familiar; the most 
characteristic of these symptoms is increase of body tem- 
perature. But it must be remembered that the height 

33 



34 NEUROTIC DISORDERS OF CHILDHOOD 

of the body temperature does not always mark the sever- 
ity of the fever process, and that even a severe and wast- 
ing fever may exist with a subnormal temperature. One 
may note at least two reasons why the temperature is 
not an index of the severity of the fever process : First, 
increased heat production is but one of the results that 
is ordinarily but not necessarily produced by the same 
causes that produce fever; second, even should heat pro- 
duction keep pace with the severity of the fever process, 
heat dissipation may be so rapid or so variable that the 
body heat at any given time would not be an index of 
the fever process. With this understanding, the terms 
fever and temperature will be used as above defined, and 
we may proceed to study the influence of the nervous 
system on these processes. 

Increased tissue metabolism, which is the one great 
cause of increased heat production, is under the direct 
control of the nervous system, and the centers which con- 
trol this metabolism, and indirectly the production of 
body heat, are called heat centers. 1 Certain of these heat 
centers have the function of discharging force which will 
increase tissue metabolism and thereby increase the body 
heat ; they are for this reason called thermogenic centers. 

Other so-called heat centers have the power of inhib- 
iting or controlling the discharge of force from the 
thermogenic centers, and they are, for this reason, called 
thermo-inhibitory centers. These thermo-inhibitory cen- 
ters have no direct influence over the processes whereby 
the body heat is produced. Yet they are of the greatest 

1 Metabolism centers might be a better name for these 
centers. 



FACTORS OF VARIABLE TEMPERATURES 35 

clinical importance because of their control over the 
thermogenic centers. 

The thermogenic and thermo-inhibitory centers have 
their functions so nicely balanced in the normal adult 
nervous mechanism that with the aid of the heat-dissi- 
pating centers they are able to maintain the body at 
almost an uniform temperature under the most adverse 
circumstances, and this temperature equilibrium can be 
disturbed only by some maladjustment of this nervous 
mechanism, which would produce either increase or de- 
crease of the body temperature. 

Where are These Heat Centers Located? — Ott, Richet, 
Sachs, Aronson, Wood, Reichert, Girard, Baginski, and 
White agree that the dominating thermogenic or heat- 
producing centers are situated at the base of the brain, 
in or near the corpus striatum. Eulenberg, Landois, 
Wood, Ott, Reichert, and White agree that important 
thermo-inhibitory centers are located in the cerebral cor- 
tex, and they are known as the cruciate and Sylvian 
centers. 

As a prelude to the use of these physiologic data in 
the explanation of some important clinical phenomena 
associated with the diseases of infancy and childhood, let 
us first inquire, what w T ould one expect, in the light of 
these facts, would be the influence on the body tempera- 
ture of disease or injury of the parts of the brain con- 
taining these centers? 

i. Destruction of that portion of the cerebral cortex 
containing the cruciate or Sylvian inhibitory heat centers 
should cause a rise of temperature, because the inhibitory 
influence of these centers on the basal thermogenic cen- 



36 NEUROTIC DISORDERS OF CHILDHOOD 

ters would be wholly or partially withdrawn. Experi- 
mental physiology confirms this deduction. This is 
probably the explanation of the fever that follows cere- 
bral hemorrhage into the cortex, and a partial explana- 
tion of the fever of insolation. 

2. Irritation of these cortical inhibitory centers should 
cause a subnormal temperature by strengthening the 
inhibitory control which they exercise over the ther- 
mogenic centers; this is also evidenced by physiologic 
experiments. We have here an explanation of the sub- 
normal temperature which may result from cortical 
meningitis and from hemorrhage, foreign bodies, or de- 
pressed bone, all of which may first act by irritating 
these cortical centers (subnormal temperature), and 
later by destroying them (increase of body temperature). 

3. Destruction of the basal thermogenic centers should 
cause a decrease of the body heat. But clinically there 
is little opportunity to observe the effect of destructive 
lesions of this portion of the brain, since any lesion suf- 
ficiently severe to destroy the basal heat centers would 
cause immediate death by the involvement of adjacent 
centers controlling vital processes. In shock we possibly 
have an example of subnormal temperature from partial 
paralysis of these centers, and. in the compression stage 
of basilar meningitis we may have a subnormal tempera- 
ture due to enfeeblement of these centers. 

4. Irritation of the basal thermogenic centers should 
cause an increase of body heat ; this fact, which is proven 
by physiologic experiment, is the explanation of the 
increased temperature that accompanies the specific 
fevers. 



FACTORS OF VARIABLE TEMPERATURES 37 

When are the Heat Centers Developed? — The answer 
to this question is in great part the answer to the ques- 
tion, Why are infants and children more prone to high 
temperatures than adults? The heat-dissipating centers 
situated in the medulla oblongata are well developed at 
birth, but these centers, because of their special clinical 
importance in infancy and childhood, will be given sepa- 
rate consideration later on. Here it is my purpose to 
note and especially emphasize the time of functional de- 
velopment of the heat-producing and the heat-inhibiting 
centers. 

Before birth the thermogenic centers are in a state of 
immature functional development. In the human infant 
born prematurely they are so imperfect that artificial 
heat is necessary for a time to keep the body heat up 
to the normal. In this respect the immature human 
foetus resembles cold-blooded animals, who are more or 
less dependent on their surroundings for their body heat. 
But as the foetus matures the thermogenic mechanism 
reaches a state of fair development, so much so that one 
may say that the thermogenic centers are functionally 
competent at birth; this of course must be so, since the 
formation of body heat is a vital process, and is, as we 
have seen, probably controlled by the same mechanism 
that controls the all-important processes of tissue metab- 
olism. While the thermogenic heat centers have a fair 
degree of development at birth, they are yet immature 
and unstable, and are therefore, like all the nerve centers 
in the unfinished brain of the child, more easily excited to 
abnormal action than are the mature heat centers of the 
adult brain. All the nerve cells of the rapidly growing 



38 NEUROTIC DISORDERS OF CHILDHOOD 

brain of the infant and child are in a state of more or 
less structural instability, since the metabolism going on 
within them must not only be rapid enough to supply 
waste, but also to furnish material for the growth and 
development of new cells. This structural and func- 
tional instability of the cells makes them more irritable 
and excitable than the nerve cells in the finished brain of 
the adult. For this reason one would expect to find the 
thermogenic heat centers of the child more excitable than 
those of the adult, and such in fact is the case. This 
is one important reason why the temperature of the in- 
fant is so variable and unstable under slight disturbing 
influences, and why like causes produce higher tempera- 
tures in the infant and child than in the adult. 

But important as this normal excitability of the im- 
mature thermogenic centers of the child may be, yet of 
far greater importance from a clinical standpoint is the 
greatly increased irritability from unfavorable conditions 
of heredity, nutrition, and environment. The thermo- 
genic heat centers of the nervous, anaemic, delicate child 
are in a state of abnormal excitability, so that a slight ex- 
citation will produce an abnormal discharge of force, 
resulting in fever and high temperature. 

But after all, probably the most important cause of the 
instability of the body temperature ki infancy and child- 
hood is to be found in the feeble control exercised by the 
cortical thermo-inhibitory centers. The thermo-inhibi- 
tory centers, like other cortical inhibitory centers pre- 
viously spoken of, have very imperfect functional de- 
velopment at birth, so that at this time they do not exert 
a very strong controlling influence over the basic thermo- 



FACTORS OF VARIABLE TEMPERATURES 39 

genie centers, and are not able to inhibit these centers 
from discharging increased energy under slightly in- 
creased excitation; for this reason slight causes may 
produce an elevation of temperature in the infant. Hale 
White says, in speaking of the thermo-inhibitory centers : 
" In the human adult they are fairly competent and 
active, as is proved by our pretty constant temperature." 
" In the lower animals and in children they are probably 
not so completely evolved, for I have found that the 
normal temperatures of rabbits vary several degrees, 
and rapid fluctuations of temperature are common in 
children even when slightly ill." 

Ott, in a personal communication, says : " It seems to 
me that children are more prone to high temperatures 
because of a loss of control of the cortical centers." 

It is, on the whole, a justifiable conclusion from all 
the evidence in our possession that the high and variable 
temperatures of infancy and childhood are in part due 
to the normal immaturity and instability of the cortical 
thermo-inhibitory centers. But, as I have previously 
noted, the feeble inhibition in the normal child is not of 
so much clinical importance as the abnormally feeble 
inhibition of the abnormal child; this is as true of the 
heat-regulating mechanism as it is of all other nervous 
mechanisms. The inhibitory part of the heat mechanism 
in its feeble and unstable state is the portion of this 
mechanism which suffers most from disease, and in its 
development is still further retarded by unfavorable con- 
ditions of heredity and environment. McAlister says: 
" The inhibitory is the first portion of the heat-regulating 
mechanism to fail under injury or disease." All of this 



40 NEUROTIC DISORDERS OF CHILDHOOD 

is quite in accord with the general observation previously 
made, that the amount of energy developed by a nerve 
cell will depend entirely on the amount of healthful 
chemical metabolism going on within it. The maxi- 
mum amount of energy being stored up in the well- 
nourished cell and the minimum amount of energy in 
the starved cell, one can readily understand how a 
malnutrition of the nerve elements resulting either from 
heredity, impoverished blood, or bad hygiene can still 
further weaken the physiologically incompetent cortical 
thermo-inhibitory centers of the child, so as to make it 
more prone to variable and to high temperatures from 
slight causes than the normal child is, since in this condi- 
tion the energy from the thermogenic centers would be 
discharged under much less restraint from the inhibitory 
centers than it is in the normal child. It may not be out 
of place here to state that the best explanation we have 
for the high and rapidly varying temperatures that not 
infrequently occur in hysterical women, is that they are 
due to the instability of the cortical thermo-inhibitory 
centers which have given way under the combined 
influence of environment, bad heredity, bad hygiene, and 
impoverished blood. 

From what has been said the following summary may 
be made of the reasons why children are more prone 
than adults to high and variable temperatures : 

1. In normal children the thermogenic centers are 
more unstable, and therefore more easily excited than in 
the adult. 

2. In normal children the thermo-inhibitory centers 
are weaker, more excitable, and therefore more incapable 



FACTORS OF VARIABLE TEMPERATURES 4 1 

of exercising proper control over the thermogenic 
centers than they are in adults. 

3. In malnourished, anaemic children the thermo- 
genic centers are far more excitable than in normal 
children ; such children are therefore more prone to high 
and variable temperatures. 

4. In malnourished, anaemic children the thermo- 
inhibitory centers are even weaker than in the normal 
child, and therefore still more incapable of restraining 
the discharge of force from the thermogenic centers ; this 
is a most important reason for the variable and high 
temperatures of such children. 

HEAT-DISSIPATING MECHANISM 

The heat-dissipating mechanism is the mechanism by 
which we keep ourselves cool. This may be done in 
three ways : 

1. By radiation and conduction of heat from the sur- 
face of the body. 

2. By constant evaporation of water from the surface 
of the body. 

3. By evaporation of water from the air passages. 
Dissipation of heat by radiation from the surface of the 

body is by far the most important means of heat dissipa- 
tion. In this process the vasomotor nervous mechanism 
is all-important. When unusual heat loss is demanded 
the vasomotor nerves dilate the blood vessels of the skin, 
and in this way expose more blood to the lower tempera- 
ture of the air. 

Loss of heat by evaporation is dependent on the 



4-2 NEUROTIC DISORDERS OF CHILDHOOD 

activity of the sweat glands, which are controlled by 
sudoriparous nerves and sweat centers. When unusual 
heat loss is demanded these centers respond by increas- 
ing the activity of the sweat glands,, which cover the 
surface of the body with fluid, and the temperature is 
lowered by its evaporation. Both the dominating vaso- 
motor and sweat centers are located in the medulla 
oblongata, and have reached good functional develop- 
ment at birth. But in the infant and young child they 
respond more readily and energetically to the demands 
for heat reduction than they do in the adult. 

It must also be kept in mind that heat loss from both 
radiation and evaporation is greater in the infant than 
in the adult, because its area of surface is greater in 
proportion to its body weight; the infant has, in fact, 
a threefold greater radiation. These are the reasons 
why the high temperatures of infancy and childhood are 
so readily reduced by the heat-dissipating mechanisms. 
The increased activity of the heat-dissipating mechanisms 
acting on a proportionately larger surface compensates 
for the increased activity of the thermogenic centers. 
In the play of function between the heat-generating 
centers and the heat-dissipating centers we have an 
explanation of the rapid variations of temperature so 
characteristic of the fevers of infancy and childhood. 

Evaporation of water from the air passages is a means 
of heat dissipation which we have yet to consider. 

In certain animals, the dog, for instance, which do not 
sweat, the evaporation of water from the air passages is 
the chief means of reducing the body temperature. 
Richet calls the rapid respirations of the panting dog 



FACTORS OE VARIABLE TEMPERATURES 43 

Polypnea. By these rapid respirations, amounting to 
as many as four hundred in a minute, the heat of the 
body is rapidly given off. Richet located the polypnoeic 
center in the medulla oblongata. Ott later located it in 
the tuber cinerium. Richet proved that the polypnoeic 
center was not affected by the amount of carbonic acid 
or oxygen in the blood, and that it was solely for the 
purpose of heat dissipation. 

In answer to the question, How is the polypnoeic 
center excited to activity? we have the experiments of 
Sihler, demonstrating that increased respiration of an 
animal exposed to heat is due to two causes, warmed 
blood and stimulation of the skin by the heat, and that 
skin stimulation is the more important factor. Gad and 
Mertschinsky also demonstrated that an increased tem- 
perature of the blood stimulates the respiratory centers 
and causes an increased number of respirations, and Ott 
produced polypncea by electrical stimulation of the tuber 
cinerium. 

Does the polypnoeic center exist and is it functionally 
active in infancy and childhood? The answer to this 
question has important clinical bearings. Ott says : " In 
infants we see a polypncea during fever; the respiration 
rises in frequency with the rise in temperature." Every 
physician must have seen many cases of rapid respiration 
in children that could not be accounted for by pulmonary 
disease. It not infrequently happens that a child with 
fever will have sixty, eighty, and one hundred respira- 
tions per minute, without presenting any sign or symp- 
tom of lung trouble. Polypncea is, to my mind, the 
explanation of this phenomenon. Very rapid breathing 



44 NEUROTIC DISORDERS OF CHILDHOOD 

is a common symptom of summer complaint, and in 
many cases means nothing more than nature's attempts 
at heat dissipation. The importance of recognizing 
polypncea as a symptom of fever in infancy and child- 
hood is great. If we do not do this, we may often be 
led, by the rapid breathing, away from the real cause of 
the disease. Fortunately for us as clinicians, there is a 
marked difference between the character of the polyp- 
nceic breathing and the rapid respirations due to lung 
or heart disease. In polypnoea, the breathing is regular, 
easy, and rapid, but is not as it is in lung and heart dis- 
ease, irregular, labored, and accompanied by cyanosis. 



CHAPTER IV 

GASTROINTESTINAL TOXAEMIA 1 

Gastro-intestinal toxaemia as differentiated from auto- 
intoxication is a systemic intoxication produced by poi- 
sons formed in and absorbed from the gastro-intestinal 
canal. Autotoxins, excreted into and afterward ab- 
sorbed from the intestinal canal, cannot, therefore, be 
classed as intestinal toxins. 

Our knowledge of the toxins which contribute to in- 
testinal intoxication is not as yet upon a very satisfactory 
chemical basis. We know, however, that the intestinal 
contents, even under normal conditions, are toxic, and 
we know, also, that under certain pathological condition 
the toxins produced by the bacterial fermentation of 
foods in the intestinal canal very greatly increase this 
toxicity, with the result that a profound systemic intoxi- 
cation is produced. Our present knowledge, however, 
is not as yet sufficient to make it profitable for us to 
attempt to differentiate, clinically, between the symptom 
groups produced by normal and abnormal intestinal 
toxins. 

INTESTINAL TOXINS 

The poisonous albumoses, which are the intermediate 
bodies formed in the digestion of albuminous food stuffs, 
may be mentioned as contributing to the toxicity of the 

1 Read before the sixteenth annual meeting of the American 
Pediatric Society, Detroit, Mich., May 30, 1904. 

45 



46 NEUROTIC DISORDERS OF CHILDHOOD 

intestinal contents, but these bodies, under normal condi- 
tions, are robbed of their toxicity in their passage 
through intestinal epithelium and liver cells, during the 
process of absorption. The body is, therefore, carefully 
guarded against intoxication from this source. It may 
be, however, that when these protective mechanisms 
fail, through disease or functional disturbances of these 
filtering organs, these bodies may act as toxins. 

Bacterial fermentation is the great source of intestinal 
toxins. It is possible that the poisons produced by bac- 
teria in the intestinal canal may have their origin from 
three different sources: 

1. The components of dead bacteria may furnish a cer- 
tain amount of proteins ; some of these bodies we know to 
be poisonous, as, for example, tuberculin, which is a pro- 
tein of the tubercule bacillus. The bacillus of glanders 
and other bacilli also contain poisonous proteins, and it is 
not impossible that poisons of this type may at times be 
a factor in producing intestinal toxaemia. The role, 
however, which these bodies play in intestinal toxaemia 
has not as yet been determined, and is probably not very 
great. 

2. Living bacteria in the intestinal canal may and do 
excrete ferments or toxins capable of producing the 
most profound nervous symptoms. These specific toxins 
of bacteria are believed to be very potent factors in pro- 
ducing intestinal toxaemia. It is evident that the char- 
acter and virulence of these toxins will depend largely 
upon the micro-organisms producing the fermentation, 
since certain micro-organisms are capable of eliminating 
much more virulent toxins than others. Whether all of 



GASTRO-INTESTINAL TOXEMIA 47 

these cell toxins belong to the ferment class is a question 
as yet undecided. Pathologists, at the present time, in- 
cline to the view that the specific toxins are closely allied 
to, if not identical with, the ferments. 

3. Substances produced by bacteria from the culture 
media are possibly the most important source of intes- 
tinal intoxication. Among the poisons of this class the 
ptomains probably hold the most important place. These 
basic compounds, resembling the alkaloids in chemical 
structure, are capable of producing the most severe sys- 
temic intoxication. The virulence of the ptomain formed 
depends not only upon the micro-organism, but also upon 
the character of the food material in which it is growing. 
Certain food materials, such as cheese, milk, meat, and 
other albuminous foods, when acted upon by certain 
bacteria, may become very poisonous owing to the 
development of poisonous ptomains. 

While ptomains are the most poisonous, and, so far as 
the etiology of intestinal toxaemia is concerned, the most 
potent of the transition products produced during the 
process of putrefaction, yet there are a large number of 
other bodies produced in this way which may also be 
factors in producing intestinal toxaemia. Among these 
bodies may be mentioned indol, skatol, phenol, cresol, 
leucin, tyrosin, ammonia, sulphuretted hydrogen, volatile 
fatty acids, oxalic acid, uric acid, and the xanthin bodies. 
Of these bodies, however, it must be said that indol is 
probably the only one whose etiological relationship to 
nervous symptoms has been satisfactorily demonstrated. 
Herter and others have recently shown that indol, one 
of the most constant and readily absorbed products of 



48 NEUROTIC DISORDERS OF CHILDHOOD 

the bacterial fermentation of albuminous food stuffs in 
the intestinal canal, is toxic, and capable of producing 
headache and increased nervous excitability. It is not 
improbable, therefore, that this body may at times, under 
the conditions named, contribute to the production of 
these symptoms. 

Indirect Etiological Factors. — Constipation is the most 
important predisposing factor of both acute and chronic 
intestinal toxaemia. It acts by retarding the passage of 
food materials along the intestinal canal ; this gives time 
for hyper-fermentation, and for the production of toxins 
by bacterial action on the intestinal contents. 

Too much food, indigestible food, and food that has 
already undergone bacterial fermentation may also be 
important factors in producing, or in prolonging, either 
an acute or chronic intestinal toxaemia. 

Lack of fresh air and exercise are also important 
predisposing factors. 

The digestive idiosyncrasies of the individual are pre- 
disposing factors which manifest themselves not infre- 
quently. These idiosyncrasies are sometimes made mani- 
fest by the taking of such foods as milk, eggs, oatmeal,, 
shell-fish, strawberries, acids, and wines. One of the 
most common of the nervous syndromes developed in 
this way is urticaria. This symptom group is not un- 
commonly associated with an acid fermentation in the 
intestinal canal, and may, in certain instances, be classed 
as an acid intoxication of intestinal origin. 

In studying the etiology of intestinal toxaemia it is 
necessary to bear in mind the important role which the 
liver plays in protecting the body against intestinal 



GASTROINTESTINAL TOXEMIA 49 

toxins. These bodies can reach the general circulation, 
and thereby produce systemic intoxication only by pass- 
ing through the liver; and in leaving the intestinal canal 
these bodies pass through the portal vein, and thence 
through the liver, to be worked over by the liver cells, 
and filtered through by way of the hepatic vein, and 
lymphatics to the general circulation. In passing 
through the liver, however, these intestinal poisons are 
under normal conditions rendered harmless. This so- 
called filtering function of the liver stands guard between 
the poisons absorbed from the intestinal canal and the 
general circulation. 

One may suppose that so long as the toxins in the 
intestinal canal are not greatly increased in quantity, 
and so long as the filtering function of the liver is intact, 
the intestinal toxins cannot produce systemic intoxica- 
tion, and one may also suppose that systemic intoxication 
may be produced by failure on the part of the liver to 
perform its function of filtering the poisonous blood in 
the portal vein, or from a great excess of intestinal 
toxins, which may so overwhelm the liver that these 
poisons find other channels of entrance into the general 
circulation. 

It is well to keep these facts in mind, since in some 
instances the liver itself may be primarily at fault in 
chronic intestinal toxaemia. This organ, therefore, must 
be kept under supervision in the treatment of all chronic 
neuroses which are supposed to be either wholly or 
partly caused by intoxications from the intestinal canal. 

Chronic intestinal toxaemia may also be an indirect 
cause of nervous symptoms, by the profound changes it 



50 NEUROTIC DISORDERS OF CHILDHOOD 

sometimes produces in the blood, contributing, as it does, 
to the production of chlorosis and other forms of chronic 
anaemia. These anaemic conditions may in turn cause 
malnutrition of nerve centers, and in that way produce 
chronic nervous irritability, and the long chain of nervous 
symptoms which are not uncommonly associated with 
profound anaemias. 

Chronic appendicitis, especially in the adult, is not an 
uncommon cause of intestinal toxaemia. This condition 
may exist for a long time without being marked by dis- 
tinct attacks of acute appendicitis. In these cases the 
symptoms of intestinal toxaemia, such as headache and 
general nervous irritability, may be associated with a 
mucous colitis, tenderness in the region of the appendix, 
an occasional colic, and ofttimes a sensation of weight 
and discomfort in that region on active exercise. 

ACUTE INTESTINAL TOXAEMIA 

Acute intestinal toxaemia is more common in the infant 
and young child than it is in the adult. This greater sus- 
ceptibility to the acute forms of intestinal toxaemia is 
probably due to a number of causes, the most important 
of which is the great irritability and the immaturity of 
the nervous system of the child. This instability of the 
nervous system of the child makes it possible for slight 
disturbing factors to produce maximum results. A 
small quantity of poison absorbed from the intestinal 
canal may, through its action on the susceptible nervous 
system, produce high fever, convulsions, and other pro- 
nounced nervous symptoms, while the same quantity of 



GASTROINTESTINAL TOXEMIA 5 I 

poison might be easily resisted by the stable nervous 
system of the adult. 

It is also true that severe albuminous fermentations 
capable of producing virulent toxins are more common 
in the child than they are in the adult. This may be due 
to the fact that the hydrochloric acid function of the 
stomach is not so well developed in the young child as 
in the adult, and therefore not capable of exercising the 
same control in preventing intestinal fermentations. It 
may also be possible that the filtering function of the 
liver, which is at all ages one of nature's safeguards 
against intestinal toxaemia, is not so well carried out in 
the child as it is in the adult. But whatever may be the 
explanation, acute intestinal toxaemia is much more 
common in the young child than in the adult. 

While our knowledge of the poisons which produce 
acute intestinal toxaemia is very unsatisfactory, yet there 
is no doubt that such a toxaemia exists, and that it is 
one of the most important factors in producing nervous 
symptoms in the young child, and a somewhat less 
important factor in producing nervous symptoms in the 
older child and the adult. Acute intestinal toxaemia 
occurs so commonly in the infant and young child that 
we are justified in suspecting this cause, where no other 
apparent cause presents, as a factor in producing sudden 
rises of temperature and acute convulsive disorders. 

The nervous symptoms which result from acute in- 
testinal toxaemia may vary in severity from a slight fever, 
with exaggerated reflexes, to a high fever and convulsive 
disorder so severe as to produce death. Every physician 
recognizes the importance of acute intestinal toxaemia as 



52 NEUROTIC DISORDERS OF CHILDHOOD 

an etiological factor in the production of dangerous 
nervous symptoms in the infant and child, and everyone 
has seen these convulsive disorders, followed by high 
fever and unconsciousness, quickly relieved by cathartic 
medication, and cured by intestinal antiseptics and diet. 

CHRONIC INTESTINAL TOXAEMIA 

Familiar as we are with acute intestinal intoxications, 
we are slow to recognize the importance of chronic in- 
testinal intoxications which are produced no doubt by 
the same intestinal toxins, absorbed in smaller quantities 
and over a longer period of time. 

As the child gets older and the nervous system de- 
velops and acquires greater powers of resistance against 
these toxins, then the acute intoxications become less, 
and the chronic intoxications more important, so that in 
the older child these severe forms of acute intestinal 
toxaemia are infrequent as compared with chronic in- 
testinal intoxications. 

It is the chronic form of intestinal intoxication to 
which I wish to call special attention, because its great 
importance as an etiological factor in producing nervous 
symptoms in children is commonly overlooked. 

Chronic intestinal toxaemia may be associated with 
diarrhoea, but is not uncommonly associated with con- 
stipation. It must be remembered that constipation may 
exist even when the child has a movement from the 
bowels every day, or even two or three movements. 
These movements may be fragmentary and therefore 
incomplete, or they may be hard and dry, showing that 



GASTROINTESTINAL TOXEMIA 53 

they have remained in the intestinal canal twenty-four 
or more hours longer than they should. 

In order to prevent hyper-fermentation, and increased 
absorption of intestinal toxins, the food materials must 
not be retarded in their passage through the intestine, 
and when ejected should be moist and have the appear- 
ance and form of the normal intestinal evacuation. 

So important, do I believe, is the role played by 
chronic intestinal toxaemia in the production of neurotic 
diseases in the child that I invariably begin the treatment 
of nervous diseases, whatever the symptom group may 
be, by a careful investigation of the intestinal canal, and 
throughout the treatment of these cases I give careful 
attention to any abnormalities of digestion. 

The child should be fed upon food carefully adjusted 
to its digestive capacity, and there should be no retarda- 
tion of food stuffs in their passage through the intestinal 
canal. 

Chronic intestinal toxaemia is probably a factor in the 
production of a large group of nervous symptoms, and 
may, as I believe, aggravate the symptoms of certain 
neuroses which are produced by etiological factors en- 
tirely foreign to the intestinal canal. Among the symp- 
toms which may be produced or exaggerated by intes- 
tinal toxaemia may be mentioned malnutrition, anaemia, 
headache, general malaise, fever, heightened reflexes, 
convulsive disorders, restlessness at night, night-terror, 
general nervous irritability, hysterical and neurasthenic 
symptoms, incontinence of urine, brachicardia, hyper- 
esthesia, paresthesia, nervous anxiety, psychoses, and, 
in rare cases, a syndrome resembling meningitis. 



54 NEUROTIC DISORDERS OF CHILDHOOD 

The following case, while somewhat unusual in the 
character of the nervous symptoms which it presents, 
may be taken as a good example of neurotic disease 
produced by intestinal toxaemia. 

SEVERE NERVOUS SYMPTOMS PRODUCED BY INTESTINAL 

TOXEMIA 

Boy, age five years, has never been strong, has had 
stomach and intestinal trouble very frequently during 
his life. At the present time he is thin, anaemic, and has 
the appearance of being malnourished. During the last 
year he has been very nervous, and this nervousness has 
recently very greatly increased, so that at the present 
time he is irritable, cries on slight provocation, is very 
restless at night, and has certain peculiar nervous attacks, 
which led his mother to seek medical advice. These 
attacks come on suddenly with dizziness; the boy falls 
to the ground, and his mother thinks he does not lose 
consciousness, and is sure he has no convulsive move- 
ments. Some minutes elapse before the boy is able to 
regain his feet. These attacks are followed immediately 
by severe headache and more or less nausea. Following 
these attacks, the boy is put to bed, and soon falls into 
a profound sleep, which may last some hours. From this 
sleep he awakes almost or quite as well as before the 
attack. 

He has had in all seven attacks during the last year, 
and three of them have occurred within the last two 
months. These attacks, which seem to occupy the border- 
land between migraine and epilepsy, have not only 
increased in frequency, but also in severity. 



GASTROINTESTINAL TOXEMIA 55 

The family history throws no light on the etiology of 
these attacks. The father is phlegmatic, the mother is 
somewhat nervous, but there is no history of neurotic 
disease in the family. 

A careful examination failed to show any reflex factors 
which might be etiologically related to this neurosis. 

The mother says that for a long time the boy has not 
been normal in his intestinal canal. Diarrhoea has alter- 
nated with constipation. There has been much flatu- 
lency. The boy has a fitful appetite, and craves food he 
should not eat. He has been fed almost anything, be- 
cause " he ate so little " the mother thought " it would 
not hurt him." 

This history strongly suggested the probability that 
the nervous symptoms might be due to intestinal 
toxaemia. 

An examination of the urine, which was high colored, 
and had a specific gravity of 1023, showed no albumin, 
no sugar, but a marked excess of indican. 

Treatment. — A dose of castor-oil, followed by a diet 
carefully regulated to suit the patient's digestive capac- 
ity; active life in the open air; a diatase and iron prep- 
aration after meals. Under this treatment the boy's 
general health gradually improved. He gained slowly 
in strength and weight. His general nervous irritability, 
which was greatly improved from the beginning of the 
treatment, gradually disappeared. He never had any of 
his peculiar attacks after the treatment was begun. Three 
months later he was discharged, well. 

Intestinal toxaemia, acute and chronic, is not an un- 
common complication of other diseases, such as typhoid 



$6 NEUROTIC DISORDERS OF CHILDHOOD 

fever, malaria, tuberculosis, and chronic diseases of the 
gastro-intestinal canal. 

As a complication this condition is probably met with 
more commonly in the convalescence from typhoid fever 
than in any other disease. The physician's unjustifiable 
fear of cathartics in this disease is ofttimes prolonged 
into the period of convalescence, and as a result fcecal 
accumulations occur, which result in an intestinal tox- 
aemia which prolongs the period of convalescence many 
weeks. 

The urine furnishes valuable evidence of the existence 
of intestinal toxaemia, and ofttimes our attention is called 
to this condition by the presence of an excess of indican, 
and the ethereal sulphates in the urine. The presence of 
these substances in the urine is sufficient reason to suspect 
a hyper-fermentation of albuminous food stuffs in the 
intestinal canal, and also usually means the retardation 
of these food stuffs in their passage through the canal, 
but the absence of indican does not rule out intestinal 
toxaemia, since we may have severe forms of intestinal 
toxaemia in which indol is not an etiological factor. 

The etiological importance of the vegetable organisms 
in producing intestinal toxaemia must not cause us to 
altogether overlook the possible role which animal para- 
sites may play in these pathological processes. In the 
present state of our knowledge, however, it is not possible 
for us to make any positive statements as to the exact 
role which intestinal worms play in producing gastro- 
intestinal toxaemia. Lynch in Grancher and Comby's 
" Maladies de l'Enfance " says that intestinal worms may 
be responsible for a large group of toxic symptoms, such 






GASTRO-INTESTINAL TOXEMIA 57 

as urticaria, ringing in the ears, syncope, vertigo, pal- 
pitation of the heart, insomnia, mental anxiety, hypo- 
chondria, general nervous irritability, fever, delirium, 
and convulsions. 

While this group of severe toxic symptoms may be 
associated with intestinal worms, it does not necessarily 
follow that they are produced by the absorption of 
poisons which have been excreted by them. Lynch him- 
self points out the possibility of these symptoms being 
produced in part, at least, by the secondary fermentations 
which the presence of these parasites excite in the intes- 
tinal canal, and notes, also, the possibility of severe 
symptoms being produced, reflexly and mechanically, by 
their action. 

Leukart observed that the ascaris lumbricoides ex- 
creted a poison capable of producing toxic symptoms. 
Huber, von Linstow, Chanson, and Raillet state that 
this same worm contains an irritating substance capable 
of producing a toxic effect on the human organism, and 
a number of other French authors state that this worm 
excretes an irritating and convulsive substance. Cao, on 
the other hand, after carefully investigating the subject, 
concludes that the evidence at the present time does not 
justify us in attributing toxic symptoms to the action of 
poisons excreted by intestinal worms. 

While there is considerable difference of opinion as to 
the etiological relationship which exists between animal 
parasites and intestinal toxins, it seems to be rather 
generally conceded that these parasites may either 
directly or indirectly produce intestinal intoxication. In 
this connection the following case is of interest. 



58 NEUROTIC DISORDERS OF CHILDHOOD 

SEVERE GENERAL CONVULSIONS PRODUCED BY NEMATODES 
IN THE INTESTINAL CANAL 

I was called in consultation to see a girl, twelve years 
of age, who had been having convulsions for several, 
hours. She was a strong, healthy German, with no 
tendency to neurotic disease. After a few days of slight 
indisposition, on the part of the intestinal canal, she 
suddenly had a severe convulsion. On my arrival I 
found that the physician in attendance had been working 
with her for some hours, and that during this time she 
had had a number of severe convulsive seizures. In the 
intervals between the convulsions she was unconscious 
and had considerable muscular rigidity. 

After controlling the convulsions with chloroform, the 
urine, drawn with a catheter, was found to be normal. 
Sulphate of magnesia was given by the mouth, and by 
rectal injections. Some hours later a large ball of round 
worms (ascaris lumbricoides) was passed with a large 
amount of foecal matter, and very soon thereafter the 
patient was restored to consciousness, and the next day 
was well. 

There can be no doubt that this was a case of 
intestinal toxaemia. The child's age, previous good 
health, and stable nervous system speak against the reflex 
origin of these convulsions ; and I may further state that 
while it is impossible for one to exclude absolutely other 
causes of intestinal intoxication, the discharges from the 
intestinal canal were not of such a character as to indi- 
cate that the poisons were produced by the fermentation 
of the intestinal contents. 



CHAPTER V 

AUTO-INTOXICATIONS 

Auto-Intoxication, which, strictly speaking-, is due to 
the presence of autogenetic toxins in the blood, is one 
of the most important, and one of the least understood, 
of all the causes of neurotic disease both in adults and in 
children. 

The close relationship of auto-toxins to certain nerv- 
ous disorders is accepted by almost all physicians as 
axiomatic, notwithstanding the fact that we have very 
little accurate knowledge of these poisons. Such nerv- 
ous syndromes as occur in diabetes, uraemia, and gout 
and certain forms of neurasthenia, hypochondriasis, and 
hysteria are among the nervous disorders which are at 
the present time believed to be etiologically related to 
auto-intoxication. 

The poisons of this class may have their origin in any 
of the three following ways : 

First. — They may be formed by the various cells of the 
body to serve some physiological purpose, and may be- 
come toxic only when accumulated in abnormal quan- 
tities in the blood and tissues. 

Second. — They may be substances which are abnor- 
mally formed through the perverted functional activity 
of the cells. Incomplete products of cell metamorphosis 
belong to this class of poisons. 

Third. — They may be produced by retrogade tissue 
59, 



60 NEUROTIC DISORDERS OE CHILDHOOD 

metamorphosis incident to the death and disintegration of 
cells. Poisons of this class become pathological fac- 
tors when they are formed in excess, or when there is 
defective elimination, or failure in the physiological 
processes which convert them into harmless bodies. 

It is evident that the body may be protected up to a 
certain point against these poisons by the increased 
activity of such excretory organs as the intestinal canal, 
the kidneys, the sweat glands, the liver, and the lungs, and 
again it is evident that the functional incapacity of these 
organs may be potent factors in precipitating an attack 
of auto-intoxication. One may therefore understand 
how in the pathology of auto-intoxications defective 
elimination and neutralization of poisons may be almost 
as important as increased production. 

The early experiments of Bouchard and others to dis- 
cover by an examination of normal urine the auto-toxins 
responsible for nervous symptoms were the first to place 
this subject on a scientific basis. These researches gave 
a wonderful impetus to the systematic study of auto- 
toxins, and led to the recognition of these bodies as dis- 
tinct factors in the production of disease. 

THYROID-INTOXICATION 

The thyroid gland is one of the organs which has its 
greatest functional activity during the early years of the 
life of the animal. This gland furnishes a secretion 
which is absolutely necessary to the normal body chemis- 
try by which normal growth and development is carried 
on. This function of the thyroid is so nicely adjusted 



AUTO-INTOXICATIONS 6 1 

to the needs of the organism over whose chemistry it 
exercises such a marvelous influence that in the vast 
majority of instances it furnishes a secretion both in 
quantity and quality nicely adjusted to the purposes it 
is to serve. 

In a few instances, however, this gland is congeni- 
tally absent, and in others its functional capacity is di- 
minished or destroyed, producing cretanism and 
myxcedema. The absence of the thyroid secretions in 
these conditions, by perverting the normal chemistry of 
the body, no doubt leads indirectly to auto-intoxications. 

On the other hand, from an increased functional 
capacity of the thyroid gland we may have an excess of 
its secretions poured into the body-media, producing a 
well-known group of nervous symptoms^ This symp- 
tom group may be produced experimentally in man by 
feeding excessive quantities of thyroid, or it may be ob- 
served in exophthalmic goiter, a disease the symptoms of 
which are now recognized by pathologists as being in 
part at least produced by thyroid-intoxication. Among 
these nervous symptoms may be mentioned headache, 
general nervous irritability, and rapid heart action. 
Every clinician has observed this symptom group to de- 
velop from thyroid feeding. 

In the infant and child we know practically nothing of 
thyroid-intoxications, yet it is my belief that such in- 
toxications exist, and that they are not an infrequent 
cause of general nervous irritability and rapid heart ac- 
tion in the child. We know that thyroid secretions in- 
crease the excitability and stimulate the growth and 
functional development of the nervous system. It seems 



62 NEUROTIC DISORDERS OF CHILDHOOD 

very probable, therefore, that, since childhood is the 
period of life when great thyroid activity is an impor- 
tant factor in producing the rapid growth and functional 
development of the nervous system, it may also be a fac- 
tor in increasing the irritability of the nervous system in 
the young child. It may, and undoubtedly does, happen 
that the amount of thyroid secretion varies with the in- 
dividual child, and that when this secretion is excessive 
it may be a factor in producing the too rapid growth and 
development of the nervous system which not uncom- 
monly occurs in children, and which, when it does occur, 
is recognized by the physicians as a factor in producing 
neurotic disease. It is not improbable, therefore, that 
rapid body growth and rapid functional development of 
the nervous system, associated with nervous irritability, 
mental precocity, tachicardia, headache, and other 
nervous symptoms, may be produced by an excessive 
activity of the thyroid gland. This hypothesis 
may explain one of the most common and one of the 
most obscure syndromes of childhood; viz., the rapid, 
irregular heart and general nervous irritability that ac- 
companies the rapid growth of children. 

It is a well-known fact that thyroid feeding will in- 
crease the output in the urine of purin bodies, and will 
aggravate the arthritic and certain other symptoms in the 
gouty patient. This may lead to the inquiry whether or 
not the symptoms of auto-intoxication produced by ex- 
cessive quantities of the thyroid secretion is not in part 
due to an increase in the products of retrograde tissue 
metamorphosis which occur as a result of the stimula- 
ting effects of thyroid secretion on the chemical pro- 



AUTO-INTOXICATIONS 63 

cesses incident to the rapid growth and functional de- 
velopment of cells. The exact modus operandi of thyroid- 
intoxication is yet to be determined. 

It may also be worthy of inquiry whether or not the 
increased activity of the thyroid gland which occurs at 
the menstrual period, especially in girls and young 
women, may not be a factor in producing the headache, 
rapid heart action, and general nervous excitability which 
occur so commonly at these periods. 

BILIARY TOXEMIA 

Biliary toxaemia is a form of auto-intoxication result- 
ing from the absorption of bile. Bouchard has shown 
that the biliary salts and the biliary coloring matters are 
poisons, the latter being much the more poisonous. 
These substances when injected into the veins of rabbits 
produce convulsions and death. From his experiments 
on rabbits Bouchard estimates that man forms in eight 
hours enough biliary poison to kill himself. These ex- 
periments, however, are not fully corroborated by clini- 
cal experience, since the absorption of considerable 
quantities of bile may go on over a long period of time, 
producing well-marked jaundice, without producing very 
severe symptoms of intoxication. The symptoms com- 
monly produced by biliary toxaemia are languor, depres- 
sion of spirits, headache, slow heart action, and itching 
of the skin, and this symptom group may continue with 
variable intensity for a long period of time without pro- 
ducing more acute or dangerous symptoms. In the 
catarrhal jaundice of children we have more or less fever, 



64 NEUROTIC DISORDERS OF CHILDHOOD 

nervous irritability, and headache — symptoms which in 
part, at least, may be due to the biliary toxaemia. Chil- 
dren suffering from more severe forms of jaundice may 
be drowsy, irritable, and may even have convulsions, fol- 
lowed by coma and death. 

It is impossible to say what part biliary toxaemia plays 
in producing these severe cerebral symptoms, which 
sometimes develop very suddenly in icteric patients. It 
has been suggested that they may be due to an acid in- 
toxication, because of the resemblance of this symptom 
group to diabetic coma. When the common bile duct is 
ligated in rabbits it is noted that the alkalinity of the 
blood gradually diminishes day by day until the death of 
the animal. But the acid intoxication in these experi- 
ments is not sufficient to justify the belief that acid intoxi- 
cations are the sole cause of the severe nervous symptoms 
above noted. Other factors not yet discovered probably 
play a role in producing these severe toxic symptoms. 

Since the above was written a paper (not yet pub- 
lished) was read before the Association of American 
Physicians by Meltzer and Salant on " The Toxicity of 
Bile." They found that bile contained two elements : 
first, a depressing or coma-producing substance; and, 
second, an exciting or tetanizing substance. These ac- 
tive principles of bile are antagonistic and normally exist 
in proper proportions to neutralize each other. This 
theory of Meltzer is offered in explanation of the fact 
that the blood may contain considerable quantities of bile 
without the existence of marked toxaemia. In such con- 
ditions the exciting and the depressing substances in the 
bile are so nicely balanced as to neutralize each other and 



AUTO-INTOXICATIONS 65 

thus produce no toxic symptoms. On the other hand, 
such an individual may be suddenly and violently 
poisoned by one or the other of the toxic principals if for 
any reason this equilibrium be destroyed. 

ACID INTOXICATIONS 

Perhaps the most tangible results of recent studies in 
auto-intoxications relate to acid intoxications. By acid 
intoxications is meant an increase of normal or abnor- 
mal acids in the body media. This increase in acids may 
result from their increased absorption from the stomach 
and intestinal canal, from their increased formation by 
the cellular elements of the body, and from the diminished 
combustion of acids. 

The inorganic acids, — hydrochloric acid, sulphuric 
acid, and phosphoric acid, — and the organic acids, — the 
volatile fatty acids, sarcolactic acid, /?-oxybutyric acid, 
diacetic acid, oxalic acid, uric acid, and carbonic acid, — 
may appear in excess in the body media and contribute to 
acid intoxications. 

It may be suggested that these acids act in producing 
pathological conditions in any one of four ways. 

First. — The acids themselves may be directly toxic. 

Second. — By union with the calcium, potassium, 
sodium, and magnesium of the blood and tissues they 
may, by the removal of these bases, produce symptoms 
directly due to the diminished quantity of one or more 
of these alkalies in the blood and tissues. These alkalies 
in definite quantities in the body media are known to be 
absolutely necessary to normal physiological processes, 



66 NEUROTIC DISORDERS OF CHILDHOOD 

and any diminution of these quantities is fraught with se- 
rious results. The alkaline content of the body media may 
also be reduced by a minimum intake of alkaline food. 

Third. — The excess of acids in the body may be com- 
bined with more or less poisonous bases, such as am- 
monium, which increase their toxicity, and the resulting 
intoxication may be partly due to the presence of large 
quantities of ammonium and other poisonous bases which 
are carried in this way through the ciiculating media on 
their way to excretion. 

I called attention, in a paper on " The Comparative 
Toxicity of Ammonium Compounds," 1 to the fact that 
in acid intoxications the degree of toxicity may in part 
depend upon the base with which the acid is united, and 
since this base is commonly ammonium, and since am- 
monium salts of the various acids are much more toxic 
than the acid themselves or the sodium or potassium salts 
of these acids, it is not impossible that the symptoms of 
an acid intoxication may be partly due to the ammonium 
ion rather than to the acid ion. This seems the more 
probable as under normal conditions there is a very small 
quantity of ammonium circulating in the blood; but in 
acid intoxications the ammonium, which under normal 
conditions is combined with C0 2 , and is converted by the 
liver into urea, is diverted from this, its normal channel, 
to form ammonium salts of the acids, and in this form is 
carried through the blood and tissues in enormous quan- 
tities to be excreted by the kidneys. 

1 " The Comparative Toxicity of Ammonium Compounds," by 
B. K. Rachford and W. H. Crane. — Transactions of Association of 
American Physicians. 1902. 



AUTO-INTOXICATIONS &7 

Fourth. — Organic or mineral acid in the blood may, 
as C. A. Herter suggests, displace the diffusible carbon 
dioxide, and appropriate the ammonium and sodium with 
which it is united. In this way an accumulation of car- 
bon dioxide may occur in the fluids and cells of the body 
which will interfere with oxidations essential to life, and 
occasion coma and death. 



DIACETIC AND /3-OXYBUTYRIC ACID INTOXICATIONS 

The protective mechanism which guards the body 
against alkaline loss is so effective that the alkalinity of 
the blood remains almost constant under ordinary patho- 
logical conditions, even those which are characterized by 
mild acid intoxications. In certain severe acid intoxi- 
cations, however, such as occur in the last stages of dia- 
betes mellitus, it appears that the alkalies of the blood may 
be drawn upon to assist in the neutralization and elimina- 
tion of the enormous quantities of $ -oxybutyric and dia- 
cetic acids which are present in the body in this condition. 
In this severe acid intoxication, after all the available 
ammonia is used up by these acids, the alkaline bases of 
the blood and tissues are seized upon and are thus carried 
in combination with acids to the kidneys to be excreted. 
The intensity of the acid intoxications in the later stages 
of diabetes mellitus is shown by the fact that eight or 
ten grammes of ammonium (not to mention other alka- 
line bases) may be excreted in combination with these 
acids in twenty-four hours. 

The symptoms which characterize severe acid intoxi- 
cations are a peculiar dyspnoea, increased pulse rate. 



68 NEUROTIC DISORDERS OF CHILDHOOD 

lowering of the body temperature, decrease in the alka- 
lescence of the blood, and increased excretion of am- 
monia. Later somnolence, coma, and death. 

Many other milder forms of /J-oxybutyric acid intoxi- 
cations have been described by Von Jacksch and others. 
Von Jacksch found acetone, diacetic acid, and /?-oxybuty- 
ric acid in excess in diseases accompanied by high fever, 
such as typhoid fever, scarlet fever, and pulmonary tuber- 
culosis. Acetone and diacetic acid are also found in con- 
siderable quantities in the later stages of carcinoma. 
And they also commonly occur in severe malnutritions, 
gastro-intestinal diseases, migraine, recurrent vomiting, 
and toxic epilepsy. What role acid intoxications play in 
producing systemic toxaemias in the above-named dis- 
eases has been determined. 

Of /5-oxybutyric acid Von Noorden says : " Owing to 
the fact that this acid is so closely related chemically to 
acetone and diacetic acid, one is justified in suspecting its 
presence in the urine whenever these two bodies are ex- 
creted in considerable quantities. As a matter of fact, one 
always succeeds in finding the acid under these circum- 
stances. ,, He also believes that "all acid intoxications 
produced by the presence in the tissues of acetone, dia- 
cetic, and /?-oxybutyric acids are due largely, if not 
wholly, to an insufficient intake of carbohydrate food, or 
to some fault in the carbohydrate metabolism. Feeding 
carbohydrates and cutting down the quantities of fats 
and albumens will always diminish and sometimes en- 
tirely overcome this form of acid intoxication." 

The origin of the acetone bodies is not at all clear, but 
in the present state of our knowledge it may be assumed 



AUTO-INTOXICATIONS 69 

that they are synthetic products derived from the break- 
ing down of the carbohydrate portion of proteid mole- 
cules, and from the disintegration of fat molecules, and 
that the disintegration of fat and proteid molecules which 
results in the formation of acetone, diacetic, and /5-oxy- 
butyric acids is influenced by the absence or scarcity of 
carbohydrate molecules. 

Clinical and laboratory experiments have apparently 
demonstrated that an excess of acetone bodies in the 
blood is due to some defect in the oxidative processes not 
altogether dependent upon a deficiency in the respiratory 
intake of oxygen. Von Noorden believes that the ab- 
sence of carbohydrates from the food influences unfavor- 
ably these oxidative processes, and leads to the formation 
of the acetone bodies. He is led to this opinion by the 
fact that this form of acid intoxication cannot occur 
when carbohydrates are taken and assimilated in proper 
quantities. 

It is my belief that the metabolic processes, the dis- 
turbance of which is responsible for diacetic and 
/5-oxybutyric acid intoxications, are largely carried on by 
the liver. The functional incapacity of the liver which 
occurs as a secondary condition in so many nutritional 
disorders may so disturb carbohydrate metabolism and 
interfere with oxidation processes that this form of acid 
intoxication may be produced. This theory is strongly 
supported by the occurrence of secondary acid intoxica- 
tions in such diseases as migraine and recurrent vomiting, 
as well as by the liver findings in cases which have had 
terminal acid intoxications. Von Noorden says : 
" Magnus-Levy, however, discovered that /2-oxybutyric 



70 NEUROTIC DISORDERS OF CHILDHOOD 

acid was a product of the autolysis of the liver, and his 
observation may, therefore, possibly be considered an 
argument in favor of the view that the liver has some- 
thing to do with the formation of acetone bodies/' 

It is a well-established fact that carbohydrate starva- 
tion will produce an excess of the acetone bodies, and it 
occurs to me that this carbohydrate starvation may be due 
either to a deficient intake of carbohydrate food or to a 
disturbance of the liver functions which interferes with 
the intake and output of carbohydrates by the liver. 

This functional incapacity of the liver which may thus 
be a factor in producing diacetic and /?-oxybutyric acid 
intoxications also throws into the circulation large quan- 
tities of ammonia which, under normal conditions, would 
be manufactured into urea. This ammonia combines 
with and saturates these acids, thus attempting to pro- 
tect the body against the threatened acid intoxications. 

CARBONIC ACID INTOXICATION 

Carbonic acid poisoning is an auto-intoxication which 
may occur in certain heart and lung diseases and severe 
anaemias and may complicate other severe acid intoxi- 
cations. 

C0 2 , which is one of the products of retrograde tissue 
metomorphosis, is formed in the tissues and conveyed by 
the blood plasma and corpuscles, to be excreted largely by 
the lungs. Poisoning from C0 2 may occur in three 
ways : 

First — By a failure on the part of the blood to carry 
the C0 2 from the tissue to the lungs for excretion. This 



AUTO-INTOXICATIONS 7 1 

may occur in heart diseases, anaemias, or in any disease of 
the circulatory system which enfeebles the capillary or 
general systemic circulation. This failure of the blood 
to remove C0 2 from the tissues results in its accumula- 
tion in such quantities in the venous blood that an auto- 
intoxication results. 

Second. — In diacetic and /S-oxybutyric acid intoxica- 
tions, as C. A. Herter suggests, the bases which ordinarily 
combine with C0 2 are in great part exhausted by other 
acids, thus allowing the C0 2 to circulate as such in the 
blood, and in that way poisoning and irritating the higher 
nerve centers. 

Third. — Diseases of the lungs, by interfering with the 
elimination of C0 2 , may also result in its accumulation 
in the blood and tissues. 

Among the symptoms ordinarily ascribed to C0 2 
poisoning are the following: Dyspnoea, mental dullness, 
stupor, unconsciousness, coma, and death. It should 
also be noted that C0 2 in the form of a salt may under 
certain pathological conditions contribute to the toxicity 
of the body media. For example, the ammonia of the 
tissues unites with C0 2 to form a carbonate of am- 
monium, and this salt is in turn converted into urea. A 
failure of the urea-forming function of the liver may 
therefore throw into the general circulation a consider- 
able quantity of carbonate of ammonium, which is passed 
through the blood to be excreted by the kidneys. Since 
carbonate of ammonium possesses a considerable degree 
of toxicity, it may be possible that it contributes to the 
systemic intoxications which occur as a result of the 
functional inactivity of the liver. 



72 NEUROTIC DISORDERS OF CHILDHOOD 



OXALIC ACID INTOXICATION 

The medical profession is by no means agreed that 
oxalic acid is ever a factor in producing auto-intoxica- 
tion. It is agreed, however, that oxalic acid is poisonous, 
and that the ammonium salt of this acid, in which form it 
is ordinarily excreted, is a very poisonous salt. Am- 
monium oxalate is in fact four times as poisonous as the 
ordinary ammonium salts, such as chloride. It is the 
oxalate ion rather than the ammonium ion which gives 
toxicity to this salt, and in experimental oxalic acid 
poisoning it is probable that this salt plays a very im- 
portant role. 

For a long time the medical profession associated a 
certain rather definite symptom group with the ap- 
pearance of an excess of oxalates in the urine. Patients 
of this type were found to be irritable, to suffer from 
headache, digestive disturbances, and insomnia, and 
were as a rule melancholic. But from the fact that an 
excess of oxalic acid might occur in the urine without pro- 
ducing any of the above-named symptoms, it was thought 
that in those cases in which nervous symptoms coincided 
with an excess of oxalates in the urine, the symptom 
group was produced by other toxins, probably intesti- 
nal in origin, which were formed at the same time. 

It seems to me, however, rather illogical, in the light of 
the uncertain chemical knowledge which we have of the 
conditions underlying the formation of oxalic acid in the 
intestinal canal and in the body tissues, and of the form 
in which it traverses the body media, to assert that oxalic 
acid, an excess of which in the urine is not uncommonly 



AUTO-INTOXICATIONS ^3 

associated with the constitutional symptoms above 
named, has no causative relation whatever to these symp- 
toms. The relationship which oxalic acid bears to this 
symptom group must be determined by further investi- 
gations. 

URIC ACID INTOXICATIONS 

In addition to the above-named syndromes associated 
with acid intoxications, there are many other symptom 
groups which are believed to be etiologically related to 
acid intoxications : such, for example, as urticaria, recur- 
rent vomiting, migraine, certain types of epilepsy, and 
other of the nervous syndromes associated with the uric 
acid diathesis. 

Perhaps no opinion not capable of absolute demonstra- 
tion is more firmly fixed in the medical mind than that the 
nervous symptoms associated with gout, and the so- 
called uric acid diathesis, are due to auto-toxins which 
are closely related in their formation and chemic proper- 
ties to uric acid and its compounds. A discussion of 
auto-intoxication, therefore, must include the possible 
role which the purin bodies may play in the production 
of these symptoms. These bodies are uric acid, adenin, 
hypoxanthin, xanthin, guanin, epiguanin, paraxanthin, 
heteroxanthin, episarkin, and carnin, and the trend of 
thought at the present time is that all of these are formed 
by the disintegration of exogenous and endogenous nu- 
cleins. The five first-named are known to be derived 
from this source. 

A most remarkable change in uric acid theories fol- 
lowed Horbaczewski's discovery that uric acid could be 



74 NEUROTIC DISORDERS OF CHILDHOOD 

formed by heating spleen pulp in the presence of fresh 
blood or peroxide of hydrogen. In these experiments 
the uric acid was formed from the disintegration of the 
splenic leucocytes — the fresh blood and peroxide of 
hydrogen acting as oxidizing agents. He observed that 
oxidizing agents were necessary to the formation of uric 
acid from nuclein9, and that, when nucleins were broken 
up by heat in the absence of oxidizing agents, the xanthin 
bases were formed. 

Previous to these observations Kossel and Salomon 
had produced adenin and hypoxanthin from the degene- 
ration of nucleins, and a number of observers had noted 
the excessive excretion of the purin bodies in leucocy- 
themia and other diseases attended by leucocytosis. The 
relationship that -exists between leucocytosis and an in- 
creased excretion of the purin bodies is not definitely un- 
derstood. Leucocytosis does not, as Kiiknau has shown, 
always mean an increased formation of purin bodies — 
the death and disintegration of the nucleins of these cells 
must precede the formation of the purin bodies. They 
have -their origin, therefore, in the death and not in the 
physiological life of these cells. Excessive cell destruc- 
tion followed by excessive nuclein disintegration always 
results in excessive formation of the purin bodies. Leu- 
cocytosis accompanied by an excessive destruction of nu- 
clein will, as a rule, produce an excess of uric acid; but 
this, however, is not always the case. In the leucocytosis 
of the severe anaemias it is a notable fact that the xanthin 
bases are increased and uric acid is decreased. The 
explanation for the excretion of xanthins and the di- 
minished excretion of uric acid in severe anaemic con- 



AUTO-INTOXICATIONS 75 

ditions associated with leucocytosis, is, as Kiiknau has 
suggested, to be found in the experiments of Horbac- 
zewski above recorded. The nuclein catabolism in anae- 
mic conditions takes place under conditions of deficient 
oxidation, and as a result xanthin bodies are formed 
instead of uric acid. It seems important, therefore, in 
the present state of our knowledge, to lay stress on the 
following facts: 

First. — Uric acid is formed when nuclein is broken 
down in the presence of oxygen. 

Second. — Xanthin bases are formed when nuclein is 
broken down in the absence of oxygen. 

Third. — Xanthin bases are not oxidized into uric acid, 
and are not, therefore, intermediate bodies in its forma- 
tion. 

Fourth. — Both uric acid and the xanthin bases may be 
oxidized into urea. The liver plays a part in this process. 

When the statement is made that uric acid and the 
xanthin bases owe their presence in the human body 
largely to the catabolism of nucleins, it must be re- 
membered that not only the leucocytes, but all the cellu- 
lar elements of the body, may contribute, through their 
death and disintegration, to the formation of these 
bodies. It is evident that as a result of normal cellular 
destruction and nuclein disintegration a certain amount 
of the alloxuric bodies must be daily formed as a normal 
physiological retrograde process ; and it must also be re- 
membered, as Umber has demonstrated, that the alloxuric 
bodies formed in the body are derived in part from the 
nucleo proteids of the food. Burian's and Shur's recent 
investigations indicate that about forty to sixty per cent. 



j6 NEUROTIC DISORDERS OF CHILDHOOD 

of the total purin content of the urine is derived from this 
source. If may be roughly estimated, therefore, that 
under normal conditions about one-half of the purin con- 
tent of the blood is exogenous and the other half endoge- 
nous. It is evident that this proportion between endoge- 
nous and exogenous purins may vary greatly in different 
individuals, and also from time to time in the same in- 
dividual. 

Under certain pathological conditions accompanied by 
an increased cell destruction and a nuclein disintegration 
the endogenous purins may be greatly increased. 

The increase of the nuclein-content in the food may 
also greatly increase the exogenous purin-content of the 
blood, and the present tendency is to attach more patho- 
logical importance to the exogenous than to the endoge- 
nous purins. The excessive intake of nucleo proteids in 
the food is therefore looked upon as probably the most 
important factor in producing an excess of purins in the 
blood. 

In studying the variation of the purin-content of the 
blood, the functional capacity of the liver must also be 
considered. This organ under normal physiological 
conditions not only converts a large proportion of the 
endogenous purins into urea, but it also stands guard 
between the purin-content of the intestinal canal and the 
general circulation. 

These bodies derived from the nucleo proteids of the 
food are filtered through the liver, and for the most part 
converted into urea before they reach the general circu- 
lation. The liver may in this manner for a long time 
protect the body against an excessive intake of exoge- 



AUTO-INTOXICATIONS JJ 

nous, or intestinal purins. Auto-intoxications from these 
purins may in this manner be prevented just so long as 
the filtering and urea- forming function of the liver can 
hold out under the increased strain of this overwork. 
But in this crisis the liver often fails, and by reason of its 
temporary functional incompetency the antecedents of 
urea, namely, the ammonium compounds and both the 
exogenous and endogenous purins, are thrown into the 
circulation, and, the excretory organs not being able to 
excrete them rapidly enough, an acute auto-intoxication 
results. Under these conditions the urine shows a de- 
crease of urea and an increase of ammonia and the purin 
bodies. 

It will be observed that in the above argument the 
temporary functional incompetency of the liver plays a 
most important role in precipitating attacks of acute sys- 
temic intoxication. In the chronic forms of auto-in- 
toxications, also, it is probable that the liver, either from 
overwork or from hereditary causes, is in a state of more 
or less chronic incompetency, and that at all times it per- 
mits a certain excess of exogenous purins to filter 
through. Acute attacks in these chronic cases being also 
caused by the occasional complete incompetency of the 
liver, and after a few hours or days of rest the liver again 
resumes its function, complete or incomplete as the case 
may be, and the acute attack is over. 

It is believed that the purin-content of the blood is un- 
der normal conditions in organic combination, and that 
the dissociation is brought about by the kidney, and the 
purin bodies excreted as such. We do not know under 
what conditions this dissociation may occur in the blood, 



78 NEUROTIC DISORDERS OF CHILDHOOD 

or under what conditions the urates are deposited in the 
tissues, especially about the small joints. Many patholo- 
gists at the present time believe that these deposits are 
secondary to necrotic changes in the part which have 
been produced by auto-toxins; that is to say, the uratic 
deposits in the tissues are secondary, and not primary, 
pathological changes. 

THEORY OF ACTION OF THE PURIN BODIES 

Uric acid and its compounds were for a long time con- 
sidered to be the all-important materies morbi of the 
nervous syndromes grouped under the general term 
lithsemia. This view has, however, been so modified in 
recent years that at the present time it is believed that 
uric acid as compared with other purin bodies plays an 
unimportant role in the production of these symptoms. 

The hypothesis that the xanthin bodies play an im- 
portant part in producing the nervous symptoms associ- 
ated with the uric acid diathesis is, as we shall see, 
supported by considerable evidence. This hypothesis 
naturally presented itself when it was demonstrated that 
uric acid and its compounds were not sufficiently toxic 
to account for the nervous symptoms of the uric acid 
diathesis, and, working upon this hypothesis, experiment- 
ers have demonstrated that a number of the xanthin 
bodies are sufficiently toxic to place them under suspicion 
as being, at least partly, responsible for the toxic symp- 
toms with which they are associated. 

Gaucher demonstrated that hypoxanthin and xanthin 
when repeatedly injected into the bodies of animals would 



AUTO-INTOXICATIONS 79 

produce degenerative changes in the excreting cells of the 
parenchyma of the kidney. 

Crofton, who recently confirmed these findings, pro- 
duced in guinea pigs by the daily injection, for six or 
eight weeks, of five per cent, solutions of xanthin and 
hypoxanthin, " a granular degeneration of the epithelial 
cells lining the tubuli contorti, and a proliferation of the 
endotheleum of the intertubular capillaries was found. 
The picture corresponds with the nephrite epitheliale of 
Gaucher." 

Kolish also produced parenchymatous degeneration of 
the kidneys of rabbits and guinea pigs by injecting small 
quantities of hypoxanthin for periods of one or two 
months. 

Hager says that a necrosis of the joint tissues is 
brought about in gout by the irritating action of certain 
of the purin bodies, particularly adenin, which he says 
is the most harmful of these bodies, and produces ne- 
crosis of tissue cells; and Kolish also believes that the 
xanthin bodies, by producing disease of the kidneys, 
prepare the way for the deposit of uric acid. 

Minkowski found that 0.5 adenin administered daily 
to dogs produced malaise, vomiting, and, after five or 
six days, death. Before death the urine of these ani- 
mals contained albumen, casts, and epithelial cells, and 
after death the kidneys showed inflammatory changes 
and uric acid deposits, and he further observed that these 
deposits occurred quite independently of the amount of 
uric acid in the urine, or of the concentration or alka- 
linity of the urine. 

Mandel found that the injection of four milligrams of 



80 NEUROTIC DISORDERS OF CHILDHOOD 

xanthin produced an elevation of temperature in a mon- 
key. He also demonstrated that in aseptic fevers there 
is a " distinct relation between the rise of temperature 
and the appearance of certain incomplete products of cell 
oxidation, as shown by the excretion of the purin 
bodies." He concludes that the purin bodies are im- 
portant factors in the production of febrile tempera- 
tures. 

These experiments are very suggestive when one con- 
siders the close relationship that exists between lithae- 
mia, arterio-sclerosis, and kidney disease in later life. I 
have been much impressed, by careful clinical observa- 
tions extending over a number of years, with the fact 
that lithsemia is one of the most important etiological 
factors in the production of arterio-sclerosis. One can 
well imagine that this condition of the arteries might re- 
sult from their long-continued irritation by reason of the 
presence of an excess of the purin bodies in the blood. 
Hypoxanthin, xanthin, and adenin, therefore, which 
have been demonstrated to have an irritating effect upon 
the kidneys, may not only be factors in the acute auto- 
intoxications of lithsemia, but may also have something to 
do with the slow arterial changes which take place in 
these patients, and in that way explain why the sick 
headaches and bilious attacks of former years are in 
later life accompanied by transient albuminurias, and 
why these patients often succumb in later life to cerebral 
hemorrhage, or uremia. 

In addition to the irritating action of xanthin on the 
kidney, it should also be stated that according to Filehne 
it has a toxic action on the nervous system, producing 



AUTO-INTOXICATIONS 8 1 

in the frog a decided muscular rigor and paralysis of the 
spinal cord. 

Paraxanthin is ^he most poisonous of the alloxuric 
bodies. Its physiological action has been studied by 
Salomon, who observed that it produced dyspnoea and a 
rigor-mortis-like contraction of muscles, followed, in the 
mouse and guinea pig, by convulsions and death. In 
the mouse these symptoms were preceded by reflex ex- 
citability. 

Heteroxanthin is also poisonous, and produces, ac- 
cording to Kriiger and Salomon, the same group of 
symptoms as paraxanthin. Heteroxanthin possesses, 
however, only one-third of the toxicity of paraxanthin. 

It is plain from the foregoing resume that the xanthin 
bodies are capable of producing disease if found in excess 
in the body media. It is important to know, therefore, 
what pathological conditions are associated with an ex- 
cess of the xanthin bodies. 

Some years ago the author advanced the theory that 
the xanthin bodies are very important factors in produc- 
ing the auto-intoxications grouped under the term 
lithaemia, and asserted the belief that these bodies are 
etiologically related to migraine, migrainous epilepsy, 
and recurrent lithaemic vomiting. He found an excess 
of the xanthin bodies in the urines of patients suffering 
from these conditions, and also found that the " final 
fluids " containing these bodies, eliminated from such 
urines, were poisonous to mice and guinea pigs. But he 
failed to find an excess of these bodies in the urines of 
these same patients in the intervals between the attacks. 

Crofton found the xanthin bodies in excess in a large 



82 NEUROTIC DISORDERS OF CHILDHOOD 

number of cases belonging to the " uratic diathesis," in- 
cluding gout. 

Kolish found in gout that uric acid was diminished 
and the xanthin bodies increased in quantity. 

A large number of observers agree that the blood in 
gout contains a considerable excess of uric acid, and that 
there is in the condition a deficient elimination of the 
purin bodies. 

The xanthin bases are spoken of as leucomains, and 
the auto-intoxication which is supposed to be produced 
by them has been called leucomain poisoning. It is my 
belief that these leucomains are factors in producing the 
forms of auto-intoxications which are described under 
the term lithsemia. No one, however, in the present state 
of our knowledge can say that these bodies are the only 
important factors of this phase of auto-intoxication. 
Future investigations will add much to our knowledge 
of the poisons engaged in this process, and will also no 
doubt disprove many things which to-day are thought 
to be of value in the study of the pathology of lithsemia. 

EXCRETION OF PURIN BODIES 

The purin bodies are excreted by the kidneys, the skin, 
and the intestinal canal. This is a matter of much 
clinical importance, since one of the most important 
questions which presents itself to the physician in the 
treatment of lithsemia is, How can the elimination of 
poisons be increased? 

The kidneys play the most important role in the ex- 
cretion of these bodies, Uric acid and the xanthin 



AUTO-INTOXICATIONS 83 

bodies are removed by the kidney cells from the blood 
into the urine, and their presence in excess in the urine 
means that immediately before their excretion they were 
in solution in excess in the blood. The kidney eliminates 
but does not manufacture or destroy these bodies. 
Severe diseases of the kidney may, therefore, cause their 
abnormal retention in the blood and other body media, 
and in this manner contribute to the nervous symptoms 
of acute and chronic Bright's disease. However this 
may be, it is certain that these bodies are excreted largely 
by the kidneys, and that we take advantage of this fact 
by stimulating these organs to increased work in the 
treatment of lithsemia. 

Purin bodies are also excreted by the skin. The skin 
is much more active in this function during the hot 
summer months than during the winter. And this may 
be one explanation for the increased liability to lithaemic 
attacks during the winter months. The undoubted value 
of many of the thermo-alkaline springs in the treatment 
of lithgemic conditions depends partly upon the fact that 
the hot bath promotes the cutaneous elimination of the 
purin bodies. In the depurative treatment of lithaemic 
attacks the skin is often stimulated to excessive action 
to relieve the acute intoxication. 

The gastro-intestinal canal is probably the most im- 
portant channel through which the purin bodies may be 
eliminated when there is defective excretion through the 
kidneys; this fact is quite empirical, and is based on the 
accumulated testimony of the medical profession for 
many years. The value of laxative medication in these 
cases, however, is probably not entirely due to the fact 



84 NEUROTIC DISORDERS OF CHILDHOOD 

that in this way the absorption of exogenous or intes- 
tinal purins may be largely prevented, but it is also prob- 
ably tfue to the fact that the intestinal canal, by proper 
cathartic medication, may be stimulated to the more 
rapid excretion of endogenous purins and other poisons 
circulating in the body media. 



CHAPTER VI 

CHRONIC SYSTEMIC BACTERIAL TOXEMIAS 

Bacterial toxins, formed in the blood and tissues of 
the body, play an important role in the etiology of the 
neuroses of childhood. We know from both laboratory 
and clinical observations that bacterial products can, by 
their direct action on nerve elements, produce most 
profound nervous symptoms. 

Bacterial products are by far the most important of 
the exciting causes of fever and high temperature in 
children. The variations in temperature accompanying 
the acute infections are largely due to the action of bac- 
terial products on the heat centers. Bodies capable of 
producing fever and variations in temperature may be 
formed by bacterial action, either within the blood and 
tissues of the animal or in wounds and cavities such as 
the intestinal canal. But wherever these bacterial prod- 
ucts may be formed, they are capable of producing 
fever and variable temperatures by their direct action on 
nerve centers. 

Centanni investigated seventeen species of bacteria and 
found in cultures of all of these, substances which when 
injected into animals caused fever with the following 
symptoms: high temperature, prostration, emaciation, 
and finally death. The toxins produced by the tetanus 
bacillus were shown, by Brieger, to be the cause of the 

85 



86 NEUROTIC DISORDERS OF CHILDHOOD 

profound nervous symptoms of that disease. From pure 
cultures of this bacillus he isolated bacterial products 
capable of producing tonic and clonic muscular spasms. 

Since these early investigations, poisonous bacterial 
products, which when injected into animals produced 
marked nervous symptoms, have been isolated from cul- 
tures of a large number of bacteria, including those of 
diphtheria, cholera, tuberculosis, typhoid fever, and septi- 
caemia, so that clinicians have now very generally come 
to believe that the nervous symptoms of the acute 
microbic diseases are in great part due to the action of 
bacterial toxins on the nervous system. 

The purpose of this chapter, however, is more es- 
pecially to call attention to the relationship of certain 
nervous diseases to those blood intoxications which 
result from such chronic microbic diseases as tubercu- 
losis, malaria, rheumatism, and syphilis. Not that the 
toxins formed in the body during the progress of acute 
microbic diseases are not all-important factors in the 
production of nervous symptoms, but that these poisons 
are not quite so intimately associated with the acute and 
chronic neuroses of childhood as are the manifold blood 
changes which the above-named chronic diseases pro- 
duce. 

Tuberculosis, of all the chronic microbic diseases, 
stands in closest etiological relationship to the neuroses 
of childhood. 

The relationship of tuberculosis to certain nervous 
diseases, more especially idiocy and insanity, has been 
noted by many medical writers. Dr. Langdon Downs 
says : " I have made an analysis of the last one hundred 



CHRONIC SYSTEMIC BACTERIAL TOXEMIAS 87 

of my post-mortem records, at the Earlswood Asylum 
for Idiots, and I find no fewer than 62 per cent, were 
subjects of tubercular deposits." 

Dr. Ireland says : " Perhaps two-thirds, or even more, 
of all idiots are of the scrofulous constitution, and fully 
two-thirds of them die of phthisis. The scrofulous 
diathesis, therefore, seems to favor, or at least to accom- 
pany, the production of idiocy." 

Dr. Clouston says of tuberculosis and insanity : " It 
is very common to find these two diseases in different 
members of the same family, and there is every reason 
to suppose from the facts that an heredity towards 
phthisis may determine insanity, and vice versa. The 
percentage of death from tuberculosis is four times 
higher among the 'insane than among the general 
population of the same ages." 

While many other writers might be cited who have 
called attention to the close clinical relationship which 
exists between tuberculosis and certain neuroses, yet I 
believe that the importance of this relationship to all the 
neuroses of childhood has not been fully recognized by 
writers upon this subject. 

The following figures, taken from the records of my 
children's clinic, prove that tuberculosis is a very common 
etiological factor of the neuroses of childhood. 

Of 407 cases of tuberculosis under fourteen years of 
a £ e > x 39 cases had, as a complication, one of the neu- 
roses; that is to say, 34 per cent, of all cases of tubercu- 
losis occurring in dispensary practice have some well- 
marked nervous affection. 

Of the 139 neurotic cases, 30 had chorea, 23 had in- 



88 NEUROTIC DISORDERS OF CHILDHOOD 

continence of urine, and 80 had such other neuroses as 
persistent headache, epilepsy, night terrors, laryngismus 
stridulus, and hysteria. 

It does not follow, of course, from the above statistics 
that tuberculosis was the sole factor in all of these cases. 
Some five or six of these children had in addition to their 
tuberculosis some rather vague evidences of chronic 
malaria, and a few of the cases of chorea, here included, 
gave slight evidence of rheumatism. Yet the tubercu- 
losis was the predominating disease in every case, and 
I think the inference is just that it was the most impor- 
tant factor in bringing about the blood state which 
produced neurotic disease in these children. 

If, instead of noting the cases of tuberculosis compli- 
cated with neurotic disease, we inquire into the per- 
centage of cases of neurotic disease showing evidence of 
tuberculosis in dispensary practice, we find the figures 
not less convincing. Of 300 cases of neurotic disease, 
I found that between 35 and 40 per cent, presented more 
or less marked evidences of tuberculosis. 

While I am quite assured that chronic tuberculosis in 
childhood is one of the most important of the etiological 
factors of the neuroses of childhood, I am not prepared 
to say that the toxins of tuberculosis are directly re- 
sponsible for the nervous symptoms. It may be that the 
blood changes incident to the chronic anaemia of tuber- 
culosis may, even apart from the specific action of the 
toxins upon the nervous centers, be etiologically related 
to these neuroses. The malnutrition of nerve elements 
must necessarily follow such profound blood changes. 

If tuberculosis is so closely related to nervous diseases 



CHRONIC SYSTEMIC BACTERIAL TOXEMIAS 89 

in children, then this fact is of great importance, since it 
is, especially among the poor, the most common disease 
of childhood. The records of my children's clinic show 
407 cases in 4400, that is to say, 10 per cent, of all cases 
treated were tuberculous. Of 10,000 cases treated in 
Steener's clinic 12 per cent, were tuberculous. And even 
this large percentage, according to Carmichael, is very 
much increased when children are crowded together 
under bad hygienic conditions and insufficiently fed. 
He concludes as follows : " On closer examination of 
400 or 500 children in the House of Industry, it was 
found that more than one-half of these unhappy children 
had the characteristic signs of scrofula in their necks." 

The prevalence of tuberculosis among the poor makes 
it a much more important etiological factor in producing 
nervous diseases among the children of this class than 
it is among the children of the rich. The reasons why 
tuberculosis is more prevalent among the poor than the 
rich are largely questions of heredity, bad hygienic 
conditions, and improper food. 

Christopher lays much stress on improper food and 
bad hygiene as important factors in the production of 
neuroses, but there can be but little doubt that these 
factors exert their worst influences among tuberculous 
children, and in this way act as contributing factors to 
the development of neurotic disease. 

Lymph node tuberculosis is the most common form 
of tuberculosis in childhood, and this is the form of the 
disease which produces the most profound blood 
changes. Children suffering from well-marked lymph 
node tuberculosis are profoundly anaemic; and this 



90 NEUROTIC DISORDERS OF CHILDHOOD 

profound anaemia must result in malnutrition of nerve 
elements. 

It is evident, therefore, that the relationship of tuber- 
culosis to the neuroses of childhood may be more or less 
complex. In part it may be due to the action of tuber- 
culous toxins on the nerve elements. The profound 
blood changes accompanying this disease may, apart 
from the toxins, be strong contributing factors; and 
bad hygiene and improper food, which have contributed 
to the development and progress of the tuberculosis, may 
also be more or less indirectly related to the nervous 
symptoms which so commonly accompany this disease. 

Rheumatism is recognized as having a close etiological 
relationship to certain of the neuroses of childhood, such 
as chorea, hysteria, and incontinence of urine. Here 
again the relationship between the primary disease and 
the nervous symptoms may be more or less complex. 
There can be little doubt that the toxin of acute 
rheumatism may, by its direct action on the nervous 
system, produce chorea, since chorea is not infrequently 
the first manifestation of the rheumatic poison; joint 
symptoms, heart symptoms, and other rheumatic mani- 
festations developing later. It is also a well-known fact 
that rheumatism in the child may be a more or less 
chronic disease, producing the profound blood changes 
which are characterized by the term chronic anaemia. 
Goodhart believes that children of rheumatic parentage 
are often habitually anaemic. Cheadle says that " the 
presence of the rheumatic poison appears to be inimical 
to the red corpuscles. It either produces their disinte- 
gration or interferes with their production." 



CHRONIC SYSTEMIC BACTERIAL TOXEMIAS 91 

Trousseau affirms that there is perhaps no acute dis- 
ease which produces anaemia so rapidly as rheumatism. 
Certain it is that rheumatism is one of the diseases of 
childhood which produces most profound blood changes, 
and in this way brings about a malnutrition of nerve 
elements which may act as a factor in the production of 
neurotic disease in children. 

Malaria is another of the chronic microbic diseases 
which holds close etiological relationship to neurotic 
disease. Headaches, neuralgias, hysteria, night terrors, 
and other nervous symptoms are frequently either 
directly or indirectly produced by the malarial poison. 

Certain periodic neuroses, such as headache and neu- 
ralgia, may undoubtedly be produced by the direct action 
of the malarial poison on the nerve elements. 

It is also probable that certain other neuroses, such as 
hysteria, incontinence of urine, general nervous irritabil- 
ity, and neurasthenia, are more or less indirectly related 
to malaria through the profound blood changes which 
occur in this disease. 

Forchheimer says : " The prime and principal lesion of 
malaria is that of the blood." ..." Malarial ca- 
chexia is the usual concomitant of chronic malaria in chil- 
dren, and children having the cachexia are emaciated 
and extremely anaemic." The relationship which this 
cachexia bears to neurotic disease in children is a well- 
established clinical fact, and it probably depends not 
alone upon the direct action of the malarial poison upon 
the nervous system, but also on the profound blood 
changes which produce malnutrition of nerve elements, 
in that way causing and predisposing to neurotic disease. 



Q2 NEUROTIC disorders OF CHILDHOOD 

Hereditary syphilis is another chronic disease of 
childhood which is also closely related to neurotic 
disease. The blood changes which occur in this condi- 
tion are very profound, and these changes, no doubt, are 
responsible for the etiological importance of inherited 
syphilis to the neuroses of childhood. 

I wish here to call attention to the fact that the four 
diseases, tuberculosis, rheumatism, malaria and syphilis, 
which in this chapter are noted as being closely related 
to the neuroses of childhood, are the four important 
chronic diseases which have latent stages and which pro- 
duce morbid changes, especially in the blood-forming 
organs of children, the lymph glands, spleen, tonsils, and 
bone marrow. 

There are many other microbic diseases, such as scar- 
let fever, diphtheria, measles, and in fact all of the other 
zymotic diseases, which are capable, through the action 
of their specific poison, of producing marked nervous 
symptoms, but they are not so closely related to the 
chronic forms of nervous disease in children, since the 
blood changes which they produce are usually acute, and 
the diseases themselves have no tendency to chronicity. 

The importance, however, of these acute zymotic 
diseases, as factors in producing nervous diseases in 
children, must not be overlooked. 



CHAPTER VII 

CHRONIC ANEMIA 

The nervous symptoms resulting from a venous condi- 
tion of the blood are almost the same as the symptoms 
produced by an arterial anaemia of the same centers. 
The reasons for this are plain, since following the liga- 
tion of arteries we have not only an arterial anaemia of 
the nerve centers, but also a compensatory venous con- 
gestion, so that in both artificial venous congestion and 
arterial anaemia we have the nerve centers bathed in 
venous blood. 

It is thought by Landois and Sterling that " the stimu- 
lation of the nerve centers which results from the ligation 
of arteries is due to the sudden interruption of the nor- 
mal exchanges of gases between blood and tissues." 

It must be remembered, however, that a venous con- 
dition of the blood which is associated with arterial 
anaemia means not only a decrease of O, and increase of 
C0 2 , but it also means more urea, more purin bodies, and 
more of all the effete products of retrograde tissue meta- 
morphosis. That is to say, the nerve tissues are not 
only deprived in part of all the substances which are 
necessary for their nutrition and healthful action, but 
they are also exposed to the irritating and poisonous 
influence of the effete products previously noted. It 
seems, therefore, a safer explanation of the symptoms 
which result from experimental arterial anaemia or ven- 

93 



94 NEUROTIC DISORDERS OF CHILDHOOD 

ous congestion of nerve centers to say that they are 
caused not only by an interruption in the normal ex- 
change of all substances necessary to the nutrition and 
healthful action of nerve tissues, but also by the presence 
in the blood of C0 2 , and other effete and poisonous 
products. 

In this connection we may note the following physio- 
logical facts concerning the influence of the above-named 
blood conditions on important nerve centers. 

A venous condition of the blood in the medulla oblon- 
gata will stimulate the vasomotor centers and cause 
constriction of the small arteries; this has been thought 
to be due to the direct stimulation of the centers by C0 2 
(Landois and Sterling). The same result may also be 
produced by an arterial anaemia of these centers due to 
ligation of arteries. 

In the medulla oblongata there is a center whose stimu- 
lation causes general spasms. This center may be excited 
either by a venous congestion or an arterial anaemia of 
the medulla oblongata. 

The respiratory center may also be excited by either 
a venous condition of the blood or by an arterial anaemia. 

Lauder Brunton cites the following experiment to 
show the relation existing between convulsive move- 
ments and a venous condition of the blood supplying 
nervous centers : " In fowls killed by cobra poison the 
convulsions came on at the moment the comb became 
livid, and when artificial respiration is begun, the con- 
vulsions disappear as the comb again regains its normal 
color." Brunton believes this to be an instance of 
asphyxial convulsions, due to irritation of the higher 



CHRONIC ANEMIA 95 

brain centers, thus diminishing their coordinating or in- 
hibiting action on the lower centers of the cord. He 
also says that " drugs which stimulate the circulation 
and increase the nutrition of the higher nerve centers 
in this way strengthen their coordinating power and tend 
to prevent spasm ; alcohol and ether act in this way." 

That this weakening of the inhibitory power of the 
brain and medulla oblongata may result from arterial 
anaemia as well as from venous congestion is shown by 
the following experiments. If the arteries going to the 
brain be ligatured so as to paralyze the medulla oblon- 
gata, then, on ligaturing the abdominal aorta, spasms of 
the lower limbs occur, owing to the anaemic stimulation 
of the motor ganglia of the spinal cord (Sigm. Meyer). 
That the anaemic condition of the cord produced by 
ligaturing the abdominal aorta is incapable of producing 
spasms when the medulla oblongata is in normal condi- 
tion, is a striking example of the inhibitory influence 
of the oblongata centers on the motor centers of the cord. 

V. Aducco made a series of valuable experiments on 
dogs. He produced anaemia of the nerve centers by cut- 
ting off a portion of the blood supply from the spinal 
motor centers. He compared the excitability of these 
centers before and after the artificial anaemia thus pro- 
duced, and in this way he determined " the effect that 
partial anaemia exercised on the motor centers of the 
cord." 

Aducco concludes his paper as follows : " The re- 
searches I have just described have led me to draw the 
following conclusions: In anaemia, that is to say when 
the flow of blood is diminished; the active materials of 



g6 NEUROTIC DISORDERS OF CHILDHOOD 

the nerve centers are found in a state of great excita- 
bility. In this condition excitants from the exterior 
act much more energetically than in the normal condi- 
tion, and this state of excitability increases, very proba- 
bly, during the entire duration of the anaemia. It seems 
to me that one should, within certain limits, admit that 
there is an inverse relation between nutrition and the ex- 
citability of the nerve elements. This latter augments 
during the time that the nutrition diminishes." 

In these conclusions, Aducco wrongly interprets arti- 
ficial arterial anaemia to mean a simple innutrition, and 
concludes that the excitability of the nerve centers is 
due to this innutrition rather than to the numerous blood 
changes which we have previously noted as accompany- 
ing arterial anaemia. 

I have repeated Aducco's experiments, and quite agree 
with him that the excitability of the nerve centers in- 
creases with the duration of the arterial anaemia; but I 
have also shown by a series of experiments, made upon 
rabbits and dogs, that the complete closure of the veins, 
returning the blood from the spinal motor centers, will 
produce the same symptoms that are produced by the 
ligature of the arteries supplying the same spinal centers. 

In these experiments I studied the increase in the 
electrical excitability in the muscles of the hind legs as 
well as the increase in the reflex excitability of these 
parts, and always obtained practically the same results 
from ligation of arteries as from ligation of veins sup- 
plying these same nerve centers. 

From the observations above cited in this chapter 
the following inferences may be made : 



CHRONIC ANEMIA 97 

1. Both arterial anaemia and venous congestion can 
produce an excitable condition of the nerve centers, and 
may therefore be factors in the production of nervous 
symptoms. 

2. The nervous symptoms resulting from arterial 
anaemia are very similar to those resulting from venous 
congestion, and this is because in both conditions there 
is a venous condition of the blood supplying the nerve 
centers. 

3. Arterial anaemia and venous congestion produce 
nervous symptoms by producing a malnutrition rather 
than a simple innutrition of the nerve centers. 

4. Arterial anaemia and venous congestion weaken 
the inhibitory centers, and this results in the discharge 
of force from reflex centers on comparatively slight 
excitation. 

5. Arterial anaemia and venous congestion make more 
excitable both the reflex centers in the cord and the more 
important reflex centers in the medulla oblongata. 

It is my belief that the above experiments offer at 
least a partial explanation of the long chain of nervous 
symptoms that are commonly associated with the com- 
plex blood condition known as chronic anaemia. These 
chronic anaemias produce a chronic malnutrition of nerve 
centers, and thus take rank among the most potent etio- 
logical factors of the neuroses of childhood. 

Chronic anaemia is a term used to express an incon- 
stant and very complex blood condition. The chronic 
anaemias of infancy and childhood are due to a great 
variety of causes, the most important of which are 
tuberculosis, rheumatism, malaria, syphilis, rachitis, 



98 NEUROTIC DISORDERS OF CHILDHOOD 

scurvy, intestinal disease, and improper food and bad 
hygiene. 

The blood in chronic anaemia is weak in proteids and 
hemoglobin, and must necessarily therefore produce a 
proteid and oxygen starvation of nerve cells. Chronic 
anaemia may also mean a diminished quantity of fat and 
of inorganic salts and an increase of the poisonous and 
irritating products produced by retrograde tissue meta- 
morphosis and bacterial action. 

In the chapters on auto-intoxication, intestinal tox- 
aemia, and bacterial toxins we have discussed the etio- 
logical relationship of bacterial poisons and auto and 
intestinal toxins to nervous symptoms. 

It is the purpose of this chapter to study certain of 
the other phases of the blood condition known as chronic 
anaemia in their etiological relationship to the neuroses 
of childhood. 

In chronic anaemias we may have the conditions which 
Christopher has described as " partial starvations " of 
nerve elements, and these conditions may be important 
factors in producing irritability of nerve cells. Such 
qualitatively starved cells are yet sufficiently well nour- 
ished to store up a large amount of nerve energy to be 
fitfully discharged. 

These partial starvations may consist in a diminished 
amount of fat, albumin, hemoglobin, oxygen, and the 
inorganic salts. It is my belief that the character of 
the nervous symptoms may vary with the character of 
this partial starvation. 

Fat starvation is a form of malnutrition which can 
best be studied in the chronic anaemia produced by rachi- 



CHRONIC ANEMIA 99 

tis. The works of Cheadle and others clearly demon- 
strate that fat starvation may be one of the important 
causes of rachitis, and the feeding of some easily digested 
fat is now accepted as a most important means in the cure 
of this disease. It must not be understood that the blood 
condition in rachitis is described by saying there is a 
diminution in the amount of fat, since there are probably 
many other blood changes, including a diminished 
amount of calcium, phosphorus, and proteid, which are 
contributing factors to the blood impoverishment of this 
disease. 

But while the blood improverishment of rachitis is 
very complex, yet by far the most important factors of 
this condition are the diminished quantity of fat and 
calcium. The deficiency of fat is a constant condition, 
and one that we know is etiologically related to rachitis. 
The inference, therefore, is probable that fat starvation 
is a form of malnutrition which may predispose to cer- 
tain well-defined neuroses, such as laryngysmus stridu- 
lus and other local and general convulsive neuroses. 

Calcium starvation may also play a part in the etiology 
of the nervous symptoms associated with rachitis. Just 
the role, however, which it plays in this condition has not 
yet been determined; certain it is, however, that experi- 
mental physiology teaches us that calcium starvation, 
whatever the conditions may be that bring it about, is 
capable of producing profound nervous disturbances. 
This subject has been studied to advantage by W. H. 
Howell, who demonstrated that the normal irritability 
of nerve and muscle tissue is in great part dependent 
upon the proper supply of calcium to these tissues. If 



100 NEUROTIC DISORDERS OF CHILDHOOD 

the heart be deprived of calcium salts, by feeding it with 
blood deprived of its calcium salts, it stops beating very- 
soon, and this action is so rapid that it could only result 
from nervous influence. The most plausible explana- 
tion of this fact is that the nerve ganglia of the heart, 
in the absence of the calcium, fail to discharge the nerve 
force which stimulates the heart muscle to contraction. 
If, on the other hand, the heart be fed with a calcium 
solution in distilled water, it will continue to beat for a 
long time. In this instance the calcium keeps up the 
irritability of the cardiac ganglia, so that they continue 
to discharge nerve force into the cardiac muscle, and the 
heart's action continues. In this explanation, which I 
have taken the liberty to make from Howell's experi- 
ments, I have attributed to calcium an important influ- 
ence over the discharge of nerve force from automatic 
centers. The presence of calcium in normal quantities 
causes these centers to discharge their nerve force into 
the cardiac muscle, as they normally do ; and the absence 
of calcium inhibits the discharge of nerve force from 
these automatic centers, and as a result the heart stops. 

If a certain amount of calcium is necessary to the 
normal irritability of nerve centers, and if the absence 
of calcium inhibits the discharge of force from nerve 
centers, then it is reasonable to infer that a diminished 
amount of calcium would have an influence on the irrita- 
bility of nerve centers which would find expression in 
clinical manifestations. That an insufficient quantity of 
calcium in the blood may produce nervous symptoms, is, 
I think, proven by Howell's experiments. He says: 
" When a frog is irritated with oxylate solutions (that 



CHRONIC ANAEMIA .101 

is to say, calcium free solutions) the muscles are affected 
quickly and in a peculiar manner. ,, ..." Twitch- 
ing movements of the toes begin in a few minutes, and 
soon extend to muscles of the leg and trunk. In some 
cases these movements were violent; strong convulsive 
contractions of muscles and limbs followed each other 
rapidly, and were often so violent as to throw the ani- 
mal out of the position in which it was lying. The con- 
vulsions resembled those caused by strychnia ; the violent 
tetanic contractions had the appearance of being caused 
by stimulation of the cord." This extremely excitable 
condition of the reflex nervous mechanism was followed 
after a time by the complete loss of irritability of this 
mechanism. 

These observations of Howell's seem to me to 
show that between the stage of the normal irritability 
of this reflex mechanism, when the calcium salts are 
supplied to it in normal quantity, and the complete 
paralysis or loss of irritability of this mechanism, due 
to the more or less complete absence of calcium salts, 
which have gradually been washed away by the calcium 
free circulating fluid, there is a stage of extreme irrita- 
bility and reflex excitability of this reflex nervous appa- 
ratus which corresponds to the period when this nervous 
mechanism is supplied with a diminished amount of cal- 
cium salts ; that is to say, there is a partial calcium starva- 
tion of the nerve elements. This explanation of Howell's 
experiments is supported by his further experiments. In 
animals in which the irritability of the reflex nervous 
apparatus had been destroyed by calcium starvation, as 
in the above experiments, it was found that if calcium 



102 NEUROTIC DISORDERS OF CHILDHOOD 

solution was added to the circulating fluid of the muscle, 
the primary effect was to again produce a twitching 
movement of these muscles, " lasting for a short while," 
to be followed by a more or less distinct return of the 
muscle to its normal irritability. 

From these and other experiments along the same line 
I conclude that calcium starvation of the nerve elements 
may be a factor in the production of the convulsive neu- 
roses of childhood. By way of parenthesis it may here 
be stated that rachitis has by some pathologists been 
classed among the acid intoxications, and the deficiency 
of calcium and other inorganic salts is thought to be due 
to this cause (see chapter on Acid Intoxications). 

However unsatisfactory our knowledge may be of 
the exact blood changes in rachitis, the fact remains 
that these blood changes, whatever they may be, are 
among the most important etiological factors in pro- 
ducing certain neuroses in infants and young children. 
Among the nervous symptoms associated with rachitis 
may be mentioned restlessness at night, muscular spasm, 
laryngismus stridulus, tetany, and general convulsions. 

Scurvy is due to some error in diet. The exact nature 
of the partial starvation which results in scurvy is not 
known. The cooking or sterilization of food, however, 
has something to do with producing this food deficiency, 
which results in the general cachexia and profound 
anaemia which characterize well-marked scurvy. 
Tremor, sleeplessness, pseudo-paralysis, pain, muscular 
tenderness, and general nervous irritability are among 
the nervous symptoms which accompany scurvy, and 
some of these, notably the sleeplessness and general irrita- 



CHRONIC ANAEMIA IO3 

bility, continue long after the active symptoms of scurvy 
have disappeared. 

Chronic gastro-enteritis is one of the important etio- 
logical factors in producing nervous symptoms in infants 
and young children. Among the nervous symptoms 
closely associated with this condition may be mentioned 
general nervous irritability, disturbed sleep, and convul- 
sive disorders, and, in older children, hysteria, neuras- 
thenia, incontinence of urine, and chorea. 

These symptom groups are, no doubt, partly due to a 
proteid, hemoglobin and oxygen starvation. These fac- 
tors, however, are probably secondary in etiological im- 
portance to the poisoning by intestinal toxins, which 
occurs in these diseases. This phase of the subject has 
been discussed in the chapter on intestinal toxins. 

Oxygen starvation, which results from impure air and 
bad hygienic surroundings, is a very important factor in 
producing anaemia, general malnutrition, and nervous 
symptoms in children. This factor is especially potent 
for evil during the first two years of life. 

Impure air and bad hygienic surroundings, by predis- 
posing to and aggravating all of the chronic diseases of 
infancy and childhood, act as powerful indirect factors 
in producing neurotic disease. The nervous symptoms 
of rachitis, scurvy, tuberculosis, intestinal diseases and 
lithaemia are greatly aggravated by oxygen starvation, 
and their cure is promoted by pure air and good hygienic 
conditions. The direct influence, however, of these fac- 
tors in producing anaemia and nervous symptoms in 
otherwise healthy children must not be overlooked. 



CHAPTER VIII 

REFLEX IRRITATION 

Reflex irritation is one of the most important etio- 
logical factors of the neuroses of childhood. Many able 
pediatrists in recent years have waged an active crusade 
against this proposition, which previously was thought to 
be one of the axioms of medical knowledge. While these 
men have not been able to convince the medical world that 
reflex irritation is an unimportant factor of neurotic 
disease, they have very much modified the view, which 
so long obtained, that reflex irritation was the all-impor- 
tant factor in producing these diseases. In the propo- 
sition as stated at the beginning of this chapter, I have 
taken position between these extreme views, and it will 
be the purpose of this chapter to show that the influence 
of reflex irritation in producing nervous diseases in 
childhood has been as much underrated in recent years 
as it was exaggerated by earlier writers, who taught that 
almost every nervous disease was caused by some reflex 
factor. It is a matter of common clinical observation 
that such neuroses as hysteria, incontinence of urine, 
night-terrors, chorea, convulsions, fever, and headache 
are at times etiologically related to some form of reflex 
irritation, and this relationship is not infrequently abso- 
lutely demonstrated when removal of the reflex irrita- 
tion cures the neurosis. 

104 



REFLEX IRRITATION 10$ 

The common sites of reflex irritations which are 
recognized factors of nervous diseases in children are 
the genito-urinary organs, the gastro-intestinal tract, the 
eye, the ear, and the nose. The importance of this sub- 
ject does not end with recognizing that reflex irritation 
from all of the above-named sites are common factors 
of neurotic disease, but it is of equal importance that we 
should recognize that, as a rule, reflex irritation acts 
conjointly with other factors in producing the neuroses 
of childhood. It is a well-known fact that reflex irrita- 
tion, of apparently a severe type, may exist without pro- 
ducing nervous symptoms. In such instances, the center, 
which is the most important part of the reflex arc, is 
normally stable, and not easily excited to discharge its 
stored-up nerve energy. It is most important, there- 
fore, that we should recognize the fact that the reflex 
irritation which excites neurotic disease is made potent 
by reason of its connection with an abnormally irritable 
reflex center. In previous chapters we have studied the 
influence of heredity, sex, age, environment, and various 
blood conditions in producing an increased irritability 
of nerve centers; and it is chiefly with the aid of these 
factors of neurotic disease that reflex irritation can pro- 
duce such a wide range of nervous symptoms. The study 
of this subject embraces, therefore, not only how each of 
these factors may act in producing nervous symptoms in 
children, but it must also inquire in individual cases into 
the interdependence and relationship of these factors 
in producing these symptoms. 

The fact that reflex irritation is commonly associated 
with other factors does not in the least diminish its 



106 NEUROTIC DISORDERS OF CHILDHOOD 

importance as a factor of neurotic disease, since the re- 
moval of the reflex excitant very commonly cures the 
neurosis, even though the other factors remain, and since 
our best efforts at removal of other factors of neurotic 
disease, as a rule, are futile for good, as long as the reflex 
excitant remains to constantly excite the nerve centers. 
The explanation of these clinical facts is that reflex 
irritation does not act simply as an excitant in discharg- 
ing nerve force from irritable centers, but it also acts 
by keeping up the irritability of these centers, and, if long 
continued, by producing changes in the nerve centers, 
recognizable under the microscope, which make these 
centers more irritable and more susceptible to reflex 
excitation. 

If this be true, then, reflex irritation at once assumes 
an important position among the factors of neurotic dis- 
ease in children; such a position, as in recent years, has 
not been accorded to it, and it is the special purpose of 
this chapter to bespeak for reflex irritation the high 
position which it merits among the factors of neurotic 
disease in children ; a position only a little less important 
than that which it formerly occupied, and from which 
it has been unjustly removed. 

The microscope has gradually revealed to us the fact 
that all cellular activity is accompanied by definite chemi- 
cal and morphological changes in the cell itself. The 
tired cell differs from the rested cell, not only in morpho- 
logical changes, which can readily be noted in nucleus 
and cell protoplasm, but also in the reaction of cell 
protoplasm and nucleus to coloring matters. 

The changes which result from the functional activity 



REFLEX IRRITATION 107 

of cells may be called fatigue changes, and it is evident 
that the longer the cell is worked, the more marked will 
be these changes. It is also a physiological fact that 
fatigue changes in the tired cell will disappear after 
a period of rest, and the cell will again be found mor- 
phologically and chemically a rested cell, but it requires 
a longer period of time for a cell to return to its rested 
condition than it does for the same cell to tire under 
ordinary work. 

The fatigue changes resulting from the functional 
activity of glandular epithelium are, as a rule, very pro- 
nounced. These changes, while not the same in all 
gland cells, may be noted in the shrunken condition of 
both nucleus and cell protoplasm and in the changed 
reactions to coloring matters of both nucleus and cell 
protoplasm. Fatigue changes in the tired muscle cell 
are also shown in the shrunken and vacuolated condition 
of its protoplasm. And both the tired muscle cell and 
the tired gland cell are only restored to their rested con- 
dition by a period of prolonged rest — the period of rest 
required being considerably longer than the period of 
activity. 

The nerve cell, like the gland and muscle cell, shows 
marked morphological and chemical fatigue changes. C. 
F. Hodge, in a very clever piece of work, has shown that 
definite changes occur in the nerve cells of the brain and 
spinal ganglia of certain birds and bees as a result of 
their normal daily activity. He compared the nerve cells 
of sparrows and swallows shot in the early morning 
with the nerve cells of sparrows and swallows shot in 
the evening after a day of hard flight. Experiments of 



108 NEUROTIC DISORDERS OF CHILDHOOD 

this kind on birds and bees invariably showed fatigue 
changes in the nerve cells tired from the day's work. 
Hodge also found definite changes to occur in the spinal 
ganglion cells of the frog, the cat, and the dog under 
electrical stimulation, and these changes were very simi- 
lar to the changes which he had observed to result from 
the normal daily activity of nerve cells. 

These fatigue changes in the nerve cells, whether re- 
sulting from normal daily activity or electrical excita- 
tion, are as follows: 

Nucleus was " much smaller, and had a jagged, irregu- 
lar outline. It took a darker stain, and lost its reticular 
appearance.' , 

Cell protoplasm " did not take stain so readily, and was 
much shrunken. In spinal ganglia it was vacuolated." 

Hodge also observed that the nerve cell recovered 
much more slowly than it tired, and that the recovery of 
the nerve cell might be represented by a curve quite 
similar to the curves obtained by Mosso and Lombard 
for the muscle cell in its recovery from fatigue. He 
concludes that " individual nerve cells after electrical 
excitation recover if allowed to rest for a sufficient time, 
but the process of recovery is slow. From five hours' 
stimulation recovery is scarcely complete after twenty- 
four hours' rest." 

The changes above noted in nerve cells, as resulting 
from electrical stimulation and normal fatigue, have a 
plain bearing on the study of the changes which occur 
in the spinal ganglia from reflex irritation, since reflex 
irritation can do nothing more than greatly exaggerate 
the functional activity of these cells, and must, therefore, 



REFLEX IRRITATION IO9 

result in changes within the cells similar to those above 
described. 

Satovski, in a careful research on " Changes in Nerve 
Cells Due to Peripheral Irritation," has made an impor- 
tant advance in our knowledge of this subject. He irri- 
tated a peripheral nerve by ligature, and thereby caused 
a peripheral, but not a central, degeneration of the nerve. 
In this way he produced a chronic reflex irritation of 
that portion of the cord to which this nerve belonged, 
and on microscopical examination of the cord at this 
point he found on the injured side, using the uninjured 
side for a control, many cells exhibiting great vacuola- 
tion and shrinking of the protoplasm from the capsule. 
The nuclei of these cells were oval instead of round, they 
stained easily, and were sometimes so much shrunken 
that they were zigzag in outline and left a space between 
the protoplasm and the nucleus of the cell. 

Ternowski, in a research on " Changes in the Spinal 
Cord from Stretching the Sciatic Nerve," found changes 
very similar to those previously noted by Satovski. 

From the observations quoted, it is plainly evident 
that chronic reflex irritation can produce very marked 
changes in the nerve cells of the spinal ganglia, and that 
the longer and more violent this irritation is, the more 
pronounced will these changes be. It is also plain that 
a considerable length of time must be required to restore 
to their normal condition cells which have been sub- 
jected to reflex irritation for months and years. It has 
even been noted that nerve cells, under electrical stimu- 
lation, can be so exhausted that the nuclei will entirely 
disappear, and the cells be unable to recover their normal 



IIO NEUROTIC DISORDERS OF CHILDHOOD 

condition even after the removal of the stimulus which 
produced the change. Here we have an explanation of 
the ofttimes slow recovery of an irritable spinal cord, 
after the removal of the reflex cause which brought 
about the irritability. In the application of these facts 
to clinical medicine, we must remember that the spinal 
cord has but two functions, viz. : conduction and reflex 
action. We must also remember that a reflex irritation 
of an afferent nerve carrying impulses to any of the cells 
of the cord does not confine its morbid influence to those 
cells, but by reason of the physiological law of " over- 
flow of reflexes " the impulse spreads up and down the 
cord, producing changes in adjacent cells; and if the 
reflex irritation be severe and long continued, the im- 
pulses may spread throughout the cord, involving all 
its cells and producing a general spinal irritability, in 
this way helping to produce in the individual a great 
variety of reflex nervous symptoms. 

In the above observations we have not only a physio- 
logical but also a morphological explanation of how and 
why chronic reflex excitation may be an important factor 
in producing general spinal irritability, and we have also 
a sufficient explanation of the fact that the removal of 
the reflex cause, which has been acting for years in pro- 
ducing spinal irritability, may not at once be followed 
by the cure of the spinal irritability, but that it may 
even require years of comparative rest for the irritable 
spinal centers to become stable (normal), even after the 
removal of the reflex cause which produced the irritability 
of these centers. These observations also justify the 
belief, arrived at by clinical observations, that reflex 



REFLEX IRRITATION I I I 

irritations, acute and chronic, are among the most im- 
portant causes of neurotic disease in children. 

In the adult such reflex factors as are produced by 
eye-strain, and diseases of the male and female genito- 
urinary organs, may be important factors in producing 
nervous symptoms. Yet reflex irritation is much more 
important in producing functional nervous diseases in 
the child than it is in the adult, for the following reasons : 

1. Reflex disturbances, such as intestinal irritation, 
adherent prepuce, and uncorrected eye-strain, are much 
more frequent in the child than in the adult. 

2. The nervous system of the child is more irritable 
and unstable by reason of its incomplete functional 
development. 

3. The inhibitory control of higher nerve centers over 
spinal reflex movements is feebly developed in the child. 

4. Blood changes such as we have described in previ- 
ous chapters are much more common allies of reflex 
factors in producing nervous diseases in children than 
they are in adults. 

5. The functional development of the male and female 
genital organs which marks the approach of puberty 
is a source of marked reflex disturbances which greatly 
predispose to neurotic diseases. 



CHAPTER IX 

EXCESSIVE NERVE ACTIVITY. 

Excessive nerve activity (the term including brain 
work and nerve excitement) is recognized as one of 
the most powerful etiological factors in producing neu- 
rasthenia, hysteria, and other neuroses in the adult, but 
notwithstanding the attention which these factors have 
received at the hands of neurologists as factors in pro- 
ducing neurotic disease in the adult, I fear that pedi- 
atrists have rather underrated them in their etiological 
relationship to the neurosis of childhood. At any rate, 
I feel sure that too little has been done to educate those 
who have the rearing and tutelage of the young to the 
importance of this subject. For only in this way can 
children be protected against the baneful influences 
which excessive brain work and nerve excitement 
produce. 

There can be no doubt that neurotic disease is, 
especially in our large cities, greatly increased by sub- 
jecting the immature nervous systems of young children 
to the almost constant excitement, strain, and mental 
activity with which our social order has surrounded them. 
An all-important question, therefore, to pediatrists who 
should be especially interested in making of the child 
the strongest possible man, is : How can these influences 
which are playing such havoc with the nervous systems 
of children be guarded against? How can they be 

112 



EXCESSIVE NERVE ACTIVITY II3 

counteracted? How can parents, guardians, nurses, and 
teachers be made to comprehend the importance of this 
subject? 

If these questions are to be answered, if the campaign 
against the evil of constantly subjecting children to the 
nervous strain resulting from the artificial conditions 
which obtain in all cities, is to be in any degree success- 
ful, then the whole subject must be placed upon a more 
exact physiological basis than it has ever been before, 
so that those who have charge of the young may be told 
not only that nervous strain is an important cause of 
neurotic disease, but that they may also be told why this 
is so. And in this series of papers on the etiology of the 
neuroses of childhood I have attempted to outline some 
of the physiological facts by which this goal is to be 
approached. 

The teachers and guardians of the young must be 
told that the nervous system of the child differs very 
materially from the nervous system of the adult; they 
must be told that the child, especially in his nervous 
organization, is not a little man; that his nervous system 
is structurally and functionally immature; that it is ex- 
citable, unstable, and under feeble inhibitory control ; that 
the sources of reflex irritation in the child are many, and 
that the nerve centers discharge their force more fit- 
fully and more readily than in the adult; that the period 
corresponding with the onset and establishment of the 
reproductive function in girls is a time when they are 
especially predisposed to nervous disease. And they 
must also be told that these and other physiological 
peculiarities of the nervous system of childhood are made 



114 NEUROTIC DISORDERS OF CHILDHOOD 

much more potent for evil when they are associated with 
the various " blood conditions " which, in previous 
chapters, I have shown to be etiologically related to the 
neuroses of childhood. 

In order to approach this subject in a physiological 
way, I shall call attention to a very extensive research 
by Dr. Wm. Townsend Porter, which has, I believe, 
great practical importance in the study of the influences 
of school life in producing the neuroses of childhood. 

Dr. Porter demonstrated that children who are ad- 
vanced in their studies are, on the average, heavier, 
taller, and of larger girth of chest than less advanced 
children of the same age. Thus, boys aged eleven were 
found in Grades I, II, III, IV, V, and VI of the St. Louis 
public schools. The average weight of the six classes 
was respectively 64, 66, 68, 71, 72, and 74 pounds. The 
ability to succeed in school life is, in the average, a meas- 
ure of mental power, and if successful scholars are, as 
a rule, better developed physically than the less success- 
ful, it follows that mental ability is, in the average, 
greater in large children than in small children of the 
same age. 

Dr. Porter makes a practical deduction from the law 
thus established. The entrance to any grade in a graded 
school system is guarded by examination, and the chil- 
dren found in that grade are such as have passed the 
entrance examination, and have in this way shown their 
capacity to do the mental labor exacted in this grade. 
The greater number of these children are of the same 
age. The work of this grade is, then, normal for this 
age, and the average height, weight, and girth of chest 



EXCESSIVE NERVE ACTIVITY 1 1 5 

of this age form the physical development most often 
found in children able to do the work of the grade. 
No child younger than the average age of any grade 
should be permitted to enter it until a physical examina- 
tion has shown that his strength shall probably be suf- 
ficient. In determining this, the relation of weight and 
girth of chest to height is of special importance. Ab- 
normal height is undoubtedly a disadvantage, yet such 
children may be strong provided their physical develop- 
ment is in proportion to their height. If the contrary 
is the case, the child will be much less able to resist the 
strain of school life. 

Dr. Porter points out the importance of frequent 
weighing of growing children. Persistent loss of weight 
in an adult is a matter of grave concern. The failure 
of a child to make the normal gain in weight is no less 
grave, and should lead to an inquiry into his school 
tasks, for the effects of prolonged overwork are very 
serious in children, and often irremediable. 

It is my belief that if there were a rule, such as Dr. 
Porter suggests, guarding every grade in our public 
school system by a physical as well as a mental examina- 
tion, it would prevent the development of a considerable 
portion of the neurotic disease which is now so preva- 
lent among school children. With children of good physi- 
cal development working in the public schools within 
the limitations of their proper grades there is almost 
no danger that a moderate amount of school work will 
in any way assist the development of neurotic disease, 
provided always that the hygienic conditions of the 
school, especially the light and ventilation, are good, 



Il6 NEUROTIC DISORDERS OF CHILDHOOD 

But the strain of ordinary school work is a very different 
matter with children of poor physical development, many 
of whom are, unfortunately, precocious. A large num- 
ber of those children, by reason of bad heredity, are 
neurotic, poorly nourished, and anaemic, and many of 
them have tuberculous, rheumatic, or syphilitic inheri- 
tances, while others, from accidental causes, such as bad 
hygiene, improper food, etc., are below the normal in 
physical development. The nervous systems of such 
children are in a condition of malnutrition, and are there- 
fore not capable of doing the ordinary work of their 
grades in the public schools, and if they are permitted 
to do this work, or if, as is often the case, these children 
are encouraged to push on into higher grades than the 
one to which their years and strength should assign them, 
disastrous consequences will surely follow, and their 
nervous systems may be injured beyond repair. 

These children under the mental strain of school work 
may develop chorea, hysteria, and other neuroses. The 
important duty, therefore, of every physician is to advise 
against much school work in children of feeble physical 
development, and to explain to parents and teachers why 
such children as these should first have their physical 
defects looked after, and should then be placed in a grade 
lower than that to which their age and intelligence would 
assign them. 

It is my belief that a normal dwarf, with no bad hered- 
itary influences behind him, may without injury to 
himself keep pace in mental development with fellows 
of his own age ; the dwarfish body is not of itself an indi- 
cation that school work might be injurious if there is 



EXCESSIVE NERVE ACTIVITY 11? 

every other evidence of perfect physical development. 
Dwarfishness of body in school children of good physique 
does not mean dwarfishness of mind. But dwarfishness 
among children, as indicated by weight and chest develop- 
ment, is, as a rule, the result of disease and bad heredity, 
and this is the reason why children who are under weight 
and have poor chest development are, as a rule, incapa- 
ble, without injury to their nervous systems, of doing 
the same amount of school work as their fellows of the 
same age. It is my belief, therefore, that the physical 
basis of precocity and dullness in children depends upon 
the facts that bad heredity and disease are the chief 
causes of abnormal dwarfishness or poor physical devel- 
opment in the young. It is also my belief that children 
of this class are, as a rule, anaemic and poorly nourished, 
and that their nervous systems are therefore in a condi- 
tion of malnutrition, and not capable of doing an amount 
of work in keeping with the age of the child. 

The reasons, then, are clear why we should not allow 
a child of poor physical development to be pushed to 
rapid brain development. If we do, their nervous sys- 
tems will surely suffer from the strain, and whatever 
predisposition they may have to neurotic disease will be 
greatly increased. In dealing with individual cases, it 
will be of the utmost importance to the physician to know 
the child's heredity ; if the child has a bad family history, 
it should be the imperative duty of the physician to pro- 
tect it against mental overwork. We cannot, of course, 
change the child's ancestry, but we can speak out against 
the crime of pushing children with hereditary physical 
defects to rapid brain development, and in this way 



Il8 NEUROTIC DISORDERS OF CHILDHOOD 

developing an hereditary nervous weakness into actual 
disease. School work may therefore be classed as a 
cause of neurotic disease in children of poor physical 
development, and it acts chiefly in calling out hereditary 
defects of the nervous system. In speaking of school 
work as a cause of neurotic disease in children, it must 
be understood that this term embraces not only brain 
work, but also the mental excitement which attends 
examinations, and the eye strain which results from 
imperfect vision and bad light, the latter being one of 
the most common causes of reflex nervous disease in chil- 
dren, and one of the physical defects which should be 
promptly removed. 

It must be remembered that what is here said of the 
physical basis of precocity and dullness is a matter of 
proof and not of opinion, and that it applies to children 
only, and has nothing whatever to do with the question 
of whether, in adult life, a healthy body adds strength 
and capacity to the nervous system. 

In this demonstration of the injury which results to 
the nervous system of the delicate child from the nervous 
strain of school life we have a most important warning 
against the pernicious habit of encouraging mental pre- 
cocity in early childhood. It is a matter of almost daily 
experience to see a poorly nourished tuberculous child 
brought forward for the purpose of demonstrating its 
" wonderful " precocity. The proud mother and over- 
zealous nurse commence the process of mental cramming 
even before infancy has passed into childhood. From this 
time on children are daily being taught, apparently with 
the idea of destroying their childhood and making of 



EXCESSIVE NERVE ACTIVITY II9 

them little men and women. And this tmphysiological 
process is not infrequently a factor in the production of 
the nervous disorders of late childhood, puberty, and 
adult life. Mothers must be told that early precocity is 
an abnormal condition in the human infant, which, if 
encouraged, may result in actual disease and permanent 
mental impairment. They must be told that vegetation 
is the ideal life of infancy and early childhood. Look to 
the physical and retard the intellectual development of 
the young child. It must not be taught, it must not be 
trained. It must have plenty of exercise, fresh air, 
proper food, and, if possible, a large portion of the year 
should be spent in the country, away from the clamor 
and excitement of city life. In the country also the 
child can have a certain amount of solitude, the impor- 
tance of which can scarcely be overestimated in giving 
independence of thought and character to the future 
man. 

It is my belief that the nurse and governess in the 
modern home are doing much to destroy the development 
of the individuality in children. The modern child has 
someone to do his thinking, someone to minister to his 
every want, and is almost constantly being trained. He 
has no time to himself, and a very small portion of his 
day is spent in play with his intellectual equals. If there 
is one crying evil common to all of our large cities it is 
the scarcity of playground for children, and the atten- 
tion of humanitarians should be called to this fact. If 
our generous citizens would pause long enough in the 
building of hospitals, libraries, and places of learning 
to realize that there is a field almost totally neglected 



120 NEUROTIC DISORDERS OF CHILDHOOD 

by the humanitarian, and one of as much importance 
to the welfare of our communities as the building of 
hospitals, libraries, and institutions of learning, then, 
possibly, a portion of the vast sums of money annually 
spent in this way would be spent in providing play- 
grounds for children. These playgrounds should not 
be covered with beautiful grass plots guarded by police- 
men, but they should be playgrounds in the best sense of 
these words; places where ball, tennis, and all kinds of 
healthful sport could be enjoyed. And I believe the day 
is not distant when the physiological importance of the 
physical, as opposed to the mental, development of chil- 
dren will be so generally recognized that many philan- 
thropists will prefer to hand their names to posterity 
associated with " playgrounds " rather than with 
fountains, art museums, music halls, and other worthy 
enterprises. 



PART II 



CHAPTER X 

FEVER 

In the chapter on the " Physiological Factors of the 
High and Variable Temperatures of Childhood " I have 
discussed the physiological peculiarities of the heat- 
regulating mechanisms of the young nervous system; 
they are, briefly, as follows : 

PHYSIOLOGICAL CAUSES OF FEVER IN CHILDHOOD 

i. The thermogenic or heat-producing centers sit- 
uated at the base of the brain are more easily excited 
to increased heat production in the immature brain of the 
young child than they are in the mature brain of the 
adult. 

2. The thermo-inhibitory or heat-controlling centers 
are weaker, and therefore less capable of exercising 
proper control over the thermogenic centers in the young 
child than they are in the adult. 

3. The heat-dissipating mechanism is much more 
efficient in the young child than it is in the adult. 

The marked excitability of the thermogenic centers, 
and the feeble control which the inhibitory centers 
exercise over them, make it possible for comparatively 
trivial exciting causes to produce high fever in the 
young child, but, on the other hand, the quick response 

123 



124 NEUROTIC DISORDERS OF CHILDHOOD 

of the very efficient heat-dissipating mechanism quickly 
lowers the body temperature. This rapid play of func- 
tion between the heat-generating and heat-dissipating 
mechanisms gives the great variability of body tempera- 
ture which characterizes the fevers of childhood. 



PREDISPOSING CAUSES OF FEVER 

1. A neurotic inheritance may increase the irritability 
of the thermogenic centers and diminish the control of 
the thermo-inhibitory centers, and in that way make the 
individual child more prone to high and variable tem- 
peratures than his fellows of the same age. A neurotic 
family history may, therefore, assist the physician in 
explaining why certain children are especially predis- 
posed to high body temperatures from slight exciting 
causes. 

2. Chronic malnutrition, by increasing the irritability 
of the thermogenic centers and by retarding the develop- 
ment of the thermo-inhibitory centers, becomes a very 
powerful predisposing cause of fever in young children. 
Chronic malnutrition implies that the nervous system, 
as well as other parts of the body, is malnourished. This 
malnutrition, as has been previously pointed out in Chap- 
ters II and III, increases the instability of the nervous 
mechanism which controls the body temperature. 

Improper food, bad hygiene, and unfavorable climatic 
conditions, with the rickets, scurvy, chronic anaemia, and 
intestinal diseases they produce, are important causes of 
malnutrition in the young child, and are therefore potent 
predisposing causes of fever at this period of life. 



FEVER 12 5 

EXCITING CAUSES OF FEVER 

The exciting causes of fever in infancy and childhood 
may be classified as follows : 

1. Bacterial products. 

2. Auto-toxins. 

3. Heat stroke. 

4. Muscular action (convulsive). 

5. Mechanical and reflex irritation. 

1. Bacterial products are by far the most important 
of the exciting causes in children. The variations in 
temperature accompanying the acute infections, includ- 
ing all forms of external and internal bacterial toxaemias, 
are due to the action of bacterial products on the heat 
centers. Bacterial products capable of producing fever 
may be formed by bacterial action, either within the 
blood and tissues of the animal or outside of the blood 
and tissues of the animal, in wounds, or in cavities, such 
as the intestinal canal, which communicate with the ex- 
ternal air. But wherever these bacterial products may 
be formed, the soluble ones are absorbed and produce 
fever by their direct action on the thermogenic centers. 
As a rule the soluble bacterial products which produce 
fever also produce a continuous increase of body tem- 
perature, and the increase of temperature is a valuable 
indication of the severity of the fever process, but this 
is a rule which has many exceptions, as is shown by -the 
normal and subnormal temperatures that occasionally 
attend pneumonia, typhoid fever, influenza, scarlatina, 
and other acute infections. The subnormal tempera- 
tures which may occur in these fevers may be explained 



126 NEUROTIC DISORDERS OF CHILDHOOD 

by the increased action of the heat-dissipating mechan- 
ism, or it may be explained by a variability in the 
potency of the bacterial products, or by a failure on the 
part of the thermogenic centers to continuously respond 
to the bacterial poisons. 

Centanni investigated seventeen pathogenic species of 
bacteria, and found in cultures of all of these germs 
a substance, not a peptone, which when injected into 
animals caused fever, with the following symptoms: 
high temperature, prostration, emaciation, and finally 
death. Omitting further discussion, I will say that the 
evidence justifies the conclusion that bacterial products 
excite fever by acting directly upon the thermogenic 
centers, and that the variations in body temperatures 
which characterize the fevers of childhood are due to a 
disturbance in the play of functions which these poisons 
produce between the heat-producing and the heat- 
dissipating centers. 

Why do bacterial products produce fever so much 
more readily in children than they do in adults? This 
question has in part been answered by our previous 
study of the peculiarities of the nervous mechanism in 
childhood which controls the body temperature. 

(a) The thermogenic centers being more unstable and 
irritable in the child, are more readily excited by bac- 
terial products. Fever and increased temperatures are 
therefore more easily produced. 

(b) The thermo-inhibitory centers being immature 
and feeble in the child, exercise but a weak restraining 
influence over the discharge of force from the thermo- 
genic centers, which are being excited by bacterial 



FEVER 127 

products; for this reason fever and increased tempera- 
tures are more easily produced by bacterial products in 
the child than in the adult. 

(c) Still another possible reason why microbic poisons 
produce fever and increase of temperature more readily 
in the child than in the adult was suggested to me by 
Professor Charles Richet, in a personal communication. 
His explanation depends on the potency of the fever 
poison more than upon the peculiarities of the nervous 
mechanism. Richet asks, Is it not possible that the 
microbic fever-producing toxins may be stronger or 
more toxic when they are produced in young organisms 
that are not protected by previous attacks of acute 
infections? That is to say, in infants and young chil- 
dren who have not had previous microbic infection and 
who are not, therefore, protected against these diseases, 
pathogenic microbes may develop more potent fever- 
producing toxins than they can later in life. 

2. Auto-toxins probably play a very unimportant 
role as exciting causes of fever in infancy and childhood. 
Some recent experiments, however, by Man-del, indicate 
that the purin bodies, when they occur in excess in the 
body tissues, may produce fever. He found that the 
injection of four milligrams of xanthin produced an 
elevation of temperature in a monkey. He also demon- 
strated that in aseptic fevers there is a distinct relation 
between the rise of temperature and the appearance of 
certain products of incomplete cell oxidation, as shown 
by the excretion of the purin bodies. He concludes that 
the purin bodies may be important factors in the 
production of febrile temperatures, 



128 NEUROTIC DISORDERS OF CHILDHOOD 

Our knowledge, however, of auto-toxins as fever 
producers is not sufficient to justify the further discus- 
sion of this subject. We do not commonly associate 
high temperatures among the symptoms of the auto- 
intoxications with which we are clinically familiar, and, 
moreover, auto-toxins are perhaps less important dis- 
ease producers in infancy and childhood than they are 
in adult life. 

3. Heat stroke is an important cause of fever, and 
high temperature in infancy and childhood. Probably 
the best explanation of the fever of heat stroke is that 
the feeble inhibitory centers of the child are still further 
weakened by the heat, so that practically no restraint is 
exercised over the thermogenic centers. Intestinal fer- 
mentation is one of the constant complications of heat 
strokes in the young child. This secondary condition, 
by the formation of intestinal toxins, acts as an im- 
portant factor in keeping up the fever in these cases. 
Cases of heat stroke in infancy and childhood are, for 
these reasons, ordinarily classed as cholera infantum, or 
enteritis, and this classification greatly obscures the direct 
etiological importance of heat as a fever producer in 
these cases. Forchheimer has for many years taught 
that many of the cases of so-called cholera infantum 
were cases of heat stroke, and that in such cases the 
intestinal fermentation is a complication rather than the 
original cause of the disease. 

The remarkable influence which outside or artificial 
heat produces on the body temperature of certain infants 
is noted by Holt, who says : " Some very puzzling and 
alarming temperatures are seen in infants as the result 



FEVER I29 

of the application of artificial heat. In one of my 
patients, an infant two days old, a temperature of 107 
F. was caused by the close proximity of two large hot- 
water bags placed in the baby's basket. The younger 
and feebler the child the more readily are such tempera- 
tures produced." 

It is evident that if such high temperatures can be 
produced in delicate children by the temporary applica- 
tion of artificial heat, the long-continued application of 
excessive heat that occurs during the mid-summer months 
must be a most potent factor in the production of fever 
and high temperature, especially in delicate children 
whose surroundings are unhygienic. 

4. Convulsive muscular action is not an infrequent 
cause of increased temperatures in infants and young 
children. The manifestation of muscular energy is 
always accompanied by the evolution of heat, and exces- 
sive muscular action, such as occurs in general convul- 
sions, is always accompanied by increased production of 
heat. This is a partial explanation of the increase of 
temperature that occurs in general spasms, but a portion 
of the increase of body heat that occurs in this condition 
may be attributed to the increased friction of the muscles, 
tendons, and articular surfaces, which transforms kinetic 
energy into heat. It should be remembered, therefore, 
that excessive muscular action may be a factor in produc- 
ing increased body heat, and that this source of heat pro- 
duction is quite distinct from that which results from 
the normal metabolism going on in muscles and other 
organs at rest, and from the abnormal metabolism going 
on in these organs during fever. I do not wish to convey 



130 NEUROTIC DISORDERS OF CHILDHOOD 

the idea that increased muscular action is the most 
common or the most important cause of the increased 
body temperature which occurs during muscular spasm, 
but only to impress the fact that violent muscular action 
is a factor in producing the increased body heat rather 
than that the increased body heat is a factor in producing 
the spasm. 

When the spasm is purely reflex in origin, the exces- 
sive muscular action may be the most important cause 
of the increased body heat; but when the spasm results 
from microbic poisons, then, no doubt, the increase of 
temperature is chiefly due to the action of these poisons 
on the heat centers. For these reasons one would expect 
to find the temperature during reflex spasm not so high 
as it is in spasm due to microbic infection, 

5. Direct mechanical and reflex irritations may pro- 
duce fever in the young child. This is more especially 
true of the nervous, malnourished infant. 

In Chapter III I have noted the fact that foreign 
bodies, growths, and exudations could act directly on 
the heat centers, to disturb the body temperature, so that 
here there only remains the consideration of the reflex 
causes of variations in the body temperatures of infants 
and young children. 

Ott says : " After the use of large doses of atropin I 
have seen the temperature rise greatly upon sciatic irri- 
tation. It was also found that this increase of tem- 
perature was accompanied by an increased production 
and augmented dissipation of heat." In these experi- 
ments we have proof that not only high temperatures, 
but also fever, may be produced reflexly. It is my belief 



FEVER 131 

that variations in the body temperature in infancy and 
childhood are not infrequently of reflex origin, and that 
the intestinal canal and the genitalia are the sites where 
reflex irritation is most likely to produce these symptoms. 
Increased temperature may occur in the malnourished 
infant and young child from the cutting of a tooth, from 
worms, undigested food, and other foreign bodies in the 
intestinal canal. The irritating products of an intestinal 
fermentation may also produce increase of temperature, 
unaided by the soluble bacterial poisons previously spoken 
of. It is a matter of every-day experience with clinicians 
that the removal of such simple causes as are here nar- 
rated will cause the temperature of the sick child to fall 
to normal, and all the other symptoms of fever to 
disappear. It will be well, therefore, in these days when 
chemistry and bacteriology are dominating medical 
pathology, for us to remember that a purely reflex fever 
can and does sometimes occur during infancy and early 
childhood. 

From the preceding outline of the possible causes of 
fever it is evident that bacterial products are by far the 
most important of these causes, and the much more 
common occurrence of fever in infancy and childhood 
is due not alone to the physiological peculiarities of the 
nervous system of the child, and the prevalence of the 
predisposing blood factors at this time of life, but it is 
also largely due to the fact that bacterial infections are 
much more common in the child than they are in the 
adult. 

The fevers of bacterial origin in infancy are largely 
due to acute and chronic gastro-intestinal toxaemias, and 



132 NEUROTIC DISORDERS OF CHILDHOOD 

the fevers of childhood are due largely to acute and 
chronic systemic bacterial toxaemias. These facts should 
be noted for the purpose of directing attention to the 
most common causes of fever in the infant and child, 
but should not obscure the fact that fevers due to other 
causes may occur at any time during the life of the 
child. 

TREATMENT 

It is always well to begin the treatment of any fever 
with a cathartic, and this is especially true if the patient 
be an infant or young child. At this period of life we 
not uncommonly observe the fever and its accompany- 
ing symptoms disappear when the intestinal canal has 
been swept clear of offending matter, but even in those 
cases where the fever is due to causes entirely apart from 
the intestinal canal, the cathartic has a very favorable 
influence in unloading the intestine and preparing it for 
the special diet which is necessary in all of these cases. 

The importance of cathartic medication in the begin- 
ning of the treatment of all fevers is important not alone 
for the purpose of overcoming an intestinal fermentation, 
or a constipation which may predispose to the develop- 
ment of intestinal toxins, but it is also important for 
the purpose of removing all reflex intestinal factors 
which may complicate and aggravate the fever by their 
influence on the excitable nervous systems of infants 
and young children. 

The intestinal canal of the child should receive atten- 
tion not only in the beginning of the fever, but it should 
be carefully guarded by a proper diet, and, if necessary, 
laxative medication through the course of the disease. 



FEVER 133 

Diet. — A fluid diet free from milk should be prescribed 
until the cause of the fever is determined. In fact, dur- 
ing the first few hours of the treatment it is better to keep 
food out of the stomach, and then small quantities of 
broth, meat juice, cereal-waters, and whisky may com- 
mence the dietetic treatment of the fever. On the second 
day the diet of the patient will depend largely upon the 
cause of the fever and the age of the patient. If the 
fever be due to an intestinal toxaemia, or to a systemic 
infection, such as la grippe or typhoid, with an accom- 
panying intestinal infection, then the diet must be care- 
fully chosen with reference to the control of the intestinal 
intoxication. In such cases milk, as a rule, is to be ex- 
cluded from the diet for a number of days, or until the 
intestinal infection is under control. But if on the second 
day one finds that the intestinal intoxication is not a fac- 
tor in producing the fever, then milk becomes an impor- 
tant article of diet, and from this time on the diet should 
be selected with reference to the age and digestive capac- 
ity of the patient, remembering always that both diges- 
tion and absorption are somewhat impaired during the 
fever process, and the patient must, therefore, be care- 
fully protected from taking food in quantity and quality 
beyond his digestive capacity. 

Jacobi says : " In ordinary fevers the food must be 
liquid and rather cool ; in vomiting, cold ; in respiratory 
diseases, warm; in collapse, hot. The best feeding time 
is the remission; in intermittent fevers nothing must 
be given during the attack except water, or acidulated 
water, now and then with an alcoholic stimulant; in 
septic fevers nothing during a chill, except either cold 



134 NEUROTIC DISORDERS OF CHILDHOOD 

or hot water, according to the wishes of the patient, with 
alcoholic stimulant. Common ephemeral catarrhal 
fevers may do without food (except water) for a reas- 
onable time. Sleep must not be disturbed, except in 
conditions of sepsis and depressed brain action. In both 
there is no sound sleep, but sopor, which should be in- 
terrupted. In sepsis (diphtheria and other) this 
rousing from sopor is an absolute necessity. Unless 
they are roused frequently to be fed sufficiently and 
stimulated freely the patients will die. Besides, in most 
of the cases the temperatures are not high, and there 
is no contra-indication to feeding on that account. 
Chronic inflammatory fevers bear and require feeding as 
generous as it must be careful. ,, 

Antipyretics. — The ice-bag, not too closely applied to 
the head, is, in my opinion, one of the most important of 
the measures we have for the control of high tempera- 
tures in the infant and child. No harm can come from 
its use if the patient is under the observation of a 
competent nurse. In very young and frail children it 
is necessary that the temperature should be taken fre- 
quently, so that when it approaches the normal the ice- 
bag may be removed. In older children the application 
of the ice-bag does not require such careful watching. 
The ice-bag is not only a very satisfactory antipyretic 
measure, but it acts very kindly in the control of the 
nervous symptoms which accompany fever. 

The bath, properly applied, is the most important of 
all agencies for reducing body temperatures in the fevers 
of infancy and childhood. It must be remembered, how- 
ever, that the cold bath cannot be used so indiscrimi- 



FEVER 135 

nately and with such uniform success in children as 
it can in the adult. Infants and young children, 
especially if they be frail and nervous, do not stand the 
cold bath well. Their young nervous systems are so 
profoundly shocked by this measure that more harm 
than good comes from it. The character of the bath, 
therefore, will depend on the age and strength of the 
child. In young and delicate children a warm or tepid 
bath, or a sponge bath with alcohol and warm water, 
will quickly reduce the body temperature. In older and 
sturdier children colder baths may be given, but it is 
rarely necessary to use a bath below 8o° F. for the con- 
trol of high temperatures in children. If the baths, as 
described above, be combined with the intelligent use of 
the ice-bag, high fevers may be readily controlled. 

Phenacetin and antipyrin, in proper doses, are, as a 
rule, perfectly safe antipyretics in all of the ephemeral 
fevers of childhood, and their good offices are marked 
not only in the reduction of the body temperature, but 
also in the control of the nervous symptoms, the child 
commonly falling asleep under their influence. 

It must be remembered that the efficiency of mild anti- 
pyretic measures in reducing high temperatures in 
infancy and childhood is due to the fact that the heat- 
dissipating mechanism in the young child is very efficient 
and responds readily to slight exciting causes. In 
Chapter III the remarkable efficiency of this mechan- 
ism has been studied from a physiological standpoint. 

In the treatment of fever, older children should be 
kept in bed, and at all ages the patient should be kept as 
quiet as possible, avoiding all excitement. 



CHAPTER XI 

ECLAMPSIA IN INFANTS AND CHILDREN 

A convulsion is a sudden discharge of motor nerve 
force, resulting in violent and rapid muscular contrac- 
tions of one or more parts of the body. It is not a 
distinct disease, but a symptom group which may be 
produced by a great variety of causes. 

ETIOLOGY 

Predisposing Causes. — Age. — Infants during the first 
few months of life have comparative immunity from 
eclampsia, but from the fourth month to the third year 
they are especially predisposed to all kinds of convulsive 
disorders. In the third year of life convulsions become 
less frequent, and from this time on in the normally 
developed child they are but slightly more common than 
they are in the adult. In Chapter II I have detailed the 
physiological peculiarities of the nervous system which 
explain the varying predisposition of the infant and 
young child to convulsive disorders. These physiological 
facts are, briefly, as follows: 

The stimulation of cortical motor centers, and of the 
convulsive centers at the base of the brain, cannot so 
readily produce convulsive disorders in the very young 
infant, because the discharge of nerve force from these 
centers is not readily communicated to the spinal reflex 

136 



ECLAMPSIA IN INFANTS AND CHILDREN 137 

centers, since at this early period of life the fibers of the 
pyramidal tracts have not fully developed their myeline 
sheaths, and are not therefore capable of readily trans- 
mitting impulses from the convulsive centers to the 
spinal cells. The development of these myeline sheaths, 
however, gradually goes on, so that the pyramidal tracts 
have their functions sufficiently developed to place the 
spinal cells and the cerebral convulsive centers in close 
touch by the time the child is three or four months of age. 

The frequency of convulsions from this time on to 
the end of the second year of life is due to the fact that 
all of the nerve centers of the infant, including the cor- 
tical motor centers and the convulsive centers at the base 
of the brain, are much more irritable, and therefore much 
more easily excited than they are later in life. At this 
period a mild exciting cause acting upon these centers 
may cause them to send a severe convulsive discharge 
through the now developed pvramidal tracts into the 
spinal cells. And owing to the fact that feeble inhibitory 
centers are exercising but a mild restraining influence 
over spinal reflex movements, we have as a result of the 
discharge of this force into the spinal cells an " over- 
flow " of reflex movements spreading up and down the 
cord, producing more or less general convulsions. 

Later in the life of the child convulsive disorders are 
less common because the whole nervous system, includ- 
ing the convulsive centers, is now less irritable and 
more stable, and the convulsive centers at the base of 
the brain and the spinal cord reflexes are under better 
inhibitory control. 

The above physiological facts are a sufficient explana- 



1 3S NEUROTIC DISORDERS OF CHILDHOOD 

tion for the varying frequency of convulsive disorders 
at different periods in the life of the infant and child. 
It should, however, be noted that the comparative im- 
munity which young infants have from convulsive dis- 
orders is in part due to the fact that at this period of life 
the acute systemic bacterial toxaemias, and the gastro- 
intestinal toxaemias, which are such potent factors in 
producing eclampsia in infants and children, are, espe- 
cially in young breast-fed infants, comparatively infre- 
quent. This partial immunity from the acute infectious 
diseases protects them against some of the most potent 
factors of the convulsive neuroses. 

Heredity. — That the tendency to convulsive disorders 
may be a direct inheritance is indicated by the fact that 
now and then whole families of children will be found 
who have convulsions upon the slightest provocation. It 
is not improbable that the hereditary tendencies in such 
families is due to the direct inheritance of an abnormally 
feeble inhibitory control of convulsive centers. On the 
other hand there may be a general neurotic inheritance 
of unstable and irritable nerve centers from neurotic 
ancestors which may predispose the child not only to con- 
vulsive disorders, but to all kinds of functional nervous 
diseases. 

Rachitis plays such an important role in the etiology 
of infantile convulsions that it is sometimes classed as a 
direct rather than an exciting cause. It matters little, 
however, whether rachitis be classed as a direct or pre- 
disposing factor so long as one remembers the close 
etiological relationship which exists between this condi- 
tion and infantile convulsions. So close, indeed, is this 



ECLAMPSIA IN INFANTS AND CHILDREN 139 

connection that convulsions during infancy should always 
lead to a careful search for other signs of rachitis. 

It has been asserted that this close relationship is due 
to the fact that the cranial bones in rachitis are in a 
state of hyperemia, and, on the other hand, it has been 
apparently demonstrated that there is an acute anaemia 
of the brain during convulsions. My own belief, how- 
ever, is that rachitis is a predisposing rather than an 
exciting factor, but that it is such a powerful predispos- 
ing factor that in advanced cases of this disease the 
infant's nervous system is in such a state of extreme 
irritability, and the basal convulsive centers and the cord 
centers are under such feeble inhibitory control, that even 
a slight irritation, toxic or reflex, which under normal 
conditions would be harmless, is sufficient to produce 
general convulsions. In examples of this kind, rachitis, 
while acting as a predisposing factor, is really the all- 
important factor in producing the eclampsia. 

Rachitis predisposes to neurotic disease in general, 
and to convulsive disorders in particular, because it is 
the most common and the most profound form of mal- 
nutrition which occurs in infancy, and because these 
evil influences are brought to bear on the unstable and 
immature nervous system while important functions, 
such as inhibition, are being developed. In rachitis, as 
noted in Chapter VII, the nerve and other tissues are 
suffering from an albumin, fat, calcium, and oxygen 
starvation, and this profound starvation of nerve ele- 
ments occurs, as a rule, during the first and second year 
of life, when the nervous system is most immature and 
most in need of good food and normal conditions for 



140 NEUROTIC DISORDERS OF CHILDHOOD 

structural and functional development. Little wonder, 
then, that rachitis exaggerates all the physiological weak- 
nesses of the infantile nervous system, and still further 
predisposes the child of this age to convulsive disorders, 
by increasing enormously the excitability of the motor 
centers in the brain and cord, and still further weakening 
the inhibitory control which the higher centers should 
exercise over the convulsive centers at the base of the 
brain and the motor centers in the spinal cord. 

The above hypothesis, I believe, explains the relation- 
ship which exists between infantile convulsions and 
rachitis, and also determines the advisability of classify- 
ing rachitis as a predisposing rather than as a direct 
exciting factor. The degree of predisposition may vary 
with the extent and severity of the rachitic process, from 
a condition of the nervous system but slightly removed 
from the normal to one in which the nervous system has 
become so unstable that even a slight excitant will 
produce a severe convulsion. 

I have discussed the relationship of rachitis to con- 
vulsive disorders, not only because this disease is itself 
such an important factor of convulsions in infancy, but 
also because it may be taken as a type of other forms 
of malnutrition, to explain how profound nutritional 
changes may be related to convulsive disorders and other 
neuroses of infancy and childhood. 

Among the other conditions which produce profound 
malnutrition in the infant, and which act as strong pre- 
disposing factors to convulsions, and neurotic disease in 
general, may be mentioned hereditary syphilis, lymph 
node tuberculosis, chronic malaria, scurvy, chronic 



ECLAMPSIA IN INFANTS AND CHILDREN I4I 

gastro-enteritis, and all other diseases producing chronic 
anaemia. As contributing factors to the chronic mal- 
nutritions which are present in all these diseases may- 
be mentioned improper food, bad air, unhygienic 
surroundings, and absence of sunlight. 

Chronic reflex irritation as a predisposing factor of 
convulsive disorders and other neuroses of infancy and 
childhood is a subject which deserves special consid- 
eration. In Chapter VIII I have detailed at length the 
profound influences which chronic reflex irritation may 
have upon spinal-cord cells. These cells, under the con- 
stant irritating influence of nagging reflexes, show 
marked pathological changes, and are put in a condition 
of extreme chronic nervous irritability. This condition, 
which may be spoken of as an irritable cord, is not an 
uncommon one in infants, and predisposes them to all 
forms of nervous disorders which have their manifesta- 
tions through the discharge of force from the spinal 
motor cells. 

Among the reflex causes which may bring about 
this chronic irritability of the nervous system may be 
mentioned, adherent prepuce, diseases of the rectum, 
bladder, and naso-pharynx, and, in older children, eye- 
strain. 

Exciting Causes. — Acute bacterial toxaemia is by far 
the most common exciting cause of infantile convulsions. 
Soluble products of bacteria, capable of producing convul- 
sions by their action on the convulsive centers at the base 
of the brain, may be formed within the blood and tissues, 
as in the acute infectious diseases so common in child- 
hood ; or they may be formed within the intestinal canal, 



142 NEUROTIC DISORDERS OF CHILDHOOD 

as in the acute gastro-intestinal infections so common in 
infancy. Since intoxications from bacterial poisons are 
by far the most common causes of eclampsia in infancy 
and childhood, and since the intestinal form of this bac- 
terial intoxication is very much more common in the 
infant, and the systemic form rather more common in 
childhood, it follows that convulsions in infancy should 
suggest to the clinician acute intestinal toxaemia, and 
convulsions in childhood should suggest the onset of 
some acute systemic bacterial infection. These sugges- 
tions, however, do not imply that gastro-intestinal tox- 
aemia may not in rare instances produce convulsions 
even in older children, 1 and that acute systemic bacterial 
infection may not occur, and be ushered in by convul- 
sions, even during the first year of life. It simply calls 
attention to the very important clinical fact that acute 
intestinal toxaemia is such an important factor in pro- 
ducing convulsions during the first and second year of 
life that in the early treatment of these cases the 
physician is justified in suspecting this cause where no 
other palpable cause presents, and it further calls atten- 
tion to the fact that systemic bacterial infection is such 
an important factor in producing convulsions in child- 
hood that the physician is also justified in suspecting, and 
is especially called upon to search for, other signs of 
acute systemic bacterial infection. 

Pneumonia, scarlet-fever, measles, and polio-myelitis, 
may be ushered in by convulsions, or the convulsions 
may occur later in these diseases. In severe types of 
malaria the convulsion may take the place of the chill. 

1 See the chapter on " Gastro-intestinal Toxaemia." 



ECLAMPSIA IN INFANTS AND CHILDREN 1 43 

Pertussis, occurring in the first and second year of life, 
is not an infrequent cause of convulsions. Holt says 
that several factors may be present in producing these 
convulsions : " Asphyxia, due to a severe paroxysm, 
cerebral congestion, or hemorrhage resulting from such 
a paroxysm, or simply the peculiar susceptibility of the 
patient, brought about by the disease itself." 

Uraemia is a factor always to be looked for in the 
convulsions of childhood, especially if the child has, or 
recently had influenza, scarlet fever, diphtheria, or other 
of the acute infections. 

Hemorrhage, if severe, may be a cause of convulsions 
by producing an acute anaemia of the nervous system. 

Insulation is a not uncommon cause of convulsions in 
infants. It probably acts by still further weakening the 
feeble inhibition of the infant, and by the high fever 
which it produces. 

Asphyxia, produced by any cause, may produce con- 
vulsions, especially in the young and feeble infant. 

Reflex Factors. — I have already noted the influence 
of chronic reflex irritation as a predisposing factor to 
convulsive disorders. This, I believe, is the most im- 
portant role which these factors play in the production 
of neurotic disease. It should be noted, however, that 
severe reflex irritation, such as may be produced by 
undigested food, worms, and other irritants in the 
intestinal canal of susceptible infants whose nervous 
systems have been rendered extremely irritable and 
unstable by chronic malnutrition, may produce convul- 
sive disorders. In such instances as this, however, the 
reflex factors would be powerless to produce neurotic 



144 NEUROTIC DISORDERS OF CHILDHOOD 

disease, if the nervous system had not been prepared for 
these explosions by powerful predisposing factors. 

The cutting of teeth in highly nervous and mal- 
nourished children suffering from rachitis or other forms 
of malnutrition may also produce severe nervous symp- 
toms, and possibly at times may be the slight exciting 
factor which touches off the highly irritable convulsive 
centers. It must always be kept in mind, however, that 
when reflex excitations are capable of producing such 
profound nervous symptoms as convulsions, there are 
other powerful and contributing factors which must be 
discovered. 

Epilepsy, which is a symptom group characterized by 
recurring convulsions, must always be suspected when 
convulsions are repeated from time to time without ap- 
parent cause. It must also, however, be kept in mind 
that infants having repeated convulsions from any of 
the causes previously named have a predisposition to 
convulsions which may disappear before they reach the 
age of six years. The retardation of development of 
inhibitory centers may explain these cases. Recurring 
convulsions, therefore, do not always mean that the child 
is to develop into an epileptic, even though the con- 
vulsions be repeated from time to time from slight ex- 
citing causes up to the fifth or sixth year. 

Convulsions may also be produced by organic lesions 
pressing on or irritating the cerebral motor centers. 
Among such causes may be mentioned meningeal hemor- 
rhage, meningitis, tumor, abscess, hydrocephalus, em- 
bolism, thrombosis, enlargement of the thymus, and in- 
jury to the skull or brain. The role, however, which 



ECLAMPSIA IN INFANTS AND CHILDREN 145 

these organic lesions play in producing general convul- 
sions in infants and children is slight as compared with 
the other non-organic factors previously detailed. More- 
over, these organic lesions should not be discussed under 
the present heading, except for differential diagnosis. 

SYMPTOMATOLOGY 

Eclampsia is a syndrome, and not a disease. Healthy 
children, however, do not suffer from convulsions. This 
symptom group always means some serious acute or 
chronic disease, the nature of which must be determined 
by other symptoms and the general history of. the case. 
Notwithstanding this fact, the importance of this 
syndrome demands that it should have separate con- 
sideration. 

There are ofttimes premonitory signs which indicate 
that eclampsia is threatened, such as sudden twitchings 
of the muscles of the arms, legs, or face. These mani- 
festations occur especially while the child is asleep. In 
many instances the physician will be called, not because 
the little patient has fever or intestinal disturbances, but 
because the mother has become alarmed at the occasional 
sudden jerkings or spasmodic contractions of the legs, 
arms, or face of her sleeping child. The child may 
continue to toss restlessly in its sleep for a time, and 
then without awakening pass suddenly into a general 
convulsion. These premonitory symptoms are more 
likely to occur during sleep, because in this condition 
voluntary inhibition is no longer active, and the excited 
motor centers for this reason the more readily respond 



I46 NEUROTIC DISORDERS OF CHILDHOOD 

to very slight reflexes, such as sudden noises and 
movements of the bed-clothes. 

In a large number of instances, however, possibly in 
the majority, the convulsive storm occurs without warn- 
ing out of a clear sky. A sudden pallor of the face is 
followed by a convulsive stiffening of the muscles, the 
eyes roll up and become fixed, spasmodic contraction of 
muscles occur; these clonic contractions may almost 
immediately become tonic, producing rigidity of the 
entire body; the face is distorted, the head drawn to one 
side, the hands are clinched upon the thumbs. Very 
shortly clonic convulsive jerkings of the head and ex- 
tremities supervene, and these severe spasmodic move- 
ments continue for three or four minutes, leaving the 
child relaxed, exhausted, and in a condition of more or 
less profound sleep, from which it may awake bright and 
conscious or without awakening may pass into a second 
convulsion. The sleep which follows the convulsion is 
ofttimes so profound as to resemble stupor or coma, 
and when the convulsions recur at short intervals the 
unconsciousness which always attends them is continued 
through the interval, producing a profound coma. The 
number of convulsions in any case will depend on the 
character and severity of the disease of which they are 
a symptom, and upon the physician's ability to remove 
or control the immediate exciting cause of the convulsive 
seizure. In the ordinary eclampsia of infancy, however, 
the patient on awakening from the sleep which follows 
the convulsion is, as a rule, bright and conscious, and 
gives little evidence of the severe nervous storm through 
which it has just passed, 



ECLAMPSIA IN INFANTS AND CHILDREN 147 

During the convulsion incontinence of urine and 
faeces is the rule; there may be spasm of the respiratory 
muscles, the breathing may be shallow, irregular, and 
spasmodic, a choking sound may be produced in the 
larynx; more or less cyanosis may occur, and in severe 
cases life may be threatened by asphyxia. 

It must not be understood, however, that the entire 
symptom group above presented will occur in every case 
of eclampsia. The severity of the convulsive seizure 
may vary from a momentary unconsciousness, with 
slight twitching of some portion of the body, to a general 
convulsion so severe as to take the life of the child, and 
comprehending in its symptomatology the entire syn- 
drome above presented. Unconsciousness and clonic or 
tonic muscular contractions (be they ever so slight) are 
the only necessary symptoms of eclampsia. 

Convulsions may be general, involving the whole body, 
or partial, involving only a member, or they may begin 
in a member and then become more or less general. 

One attack of eclampsia does not predispose to another 
unless some organic injury to the nervous centers results 
from the convulsive seizure. The same predisposing 
causes, however, which made possible the first convulsion 
may account for subsequent attacks from slight exciting 
causes. 

PROGNOSIS 

Age is a very important factor in prognosis. Eclamp- 
sia is a very serious condition when it occurs during the 
early days of the life of the child. It is very much less 
serious when it occurs between the end of the third 
month and the second year of life. It is again more 



I48 NEUROTIC DISORDERS OF CHILDHOOD 

serious in the third year of life, and becomes more so 
as the child grows older. 

In the newly born the prognosis is bad, because only 
serious brain lesions, such as cerebral hemorrhage or 
congenital defects, are likely to produce general con- 
vulsions at this age. For these reasons convulsive 
disorders which have their origin during the first week 
of life have a very serious prognosis, since spastic 
palsies or epilepsy commonly supervene. 

After the first week of life, when the infant has recov- 
ered from the accidents of birth and has become accus- 
tomed to its new surroundings, convulsions are rather 
uncommon until after the third month of life. If, how- 
ever, convulsions should begin between the second week 
and the fourth month of life, while they are not so 
ominous in their import as those occurring during the 
first week, yet they are more serious than those that occur 
during infancy after the third month, because the nervous 
system has not yet sufficiently developed to predispose 
the infant to convulsive disorders, and it therefore re- 
quires some severe form of irritation (organic or toxic) 
to produce convulsive disorders. 

Between the fourth month and the end of the second 
year, as has been previously noted, is the time when 
convulsions most readily occur and when the prognosis 
is at the best. At this period of life, however, convul- 
sions may be fatal, or may herald some serious disease; 
yet in the great majority of instances they are from com- 
paratively trivial and quickly removable causes, and for 
these reasons the prognosis is especially good. 

After the second year, as the growth and functional 



ECLAMPSIA IN INFANTS AND CHILDREN 1 49 

development of the nervous system, in the normal child, 
gradually removes the predisposition to convulsive dis- 
orders, eclampsia requires for its production more potent 
etiological factors, has a graver prognosis, and becomes 
less and less frequent, so that at the age of five or six 
years it suggests some severe constitutional intoxication, 
such as uraemia, or one of the acute infectious diseases, 
such as meningitis, scarlet fever, or pneumonia. 

Apart from the age of the child there are a number 
of indications which assist us in making an early 
prognosis. 

1. A severe initial convulsion, deep supervening coma, 
and a tendency to tonic contractions in the intervals 
between the convulsions suggest a most unfavorable 
prognosis, not only so far as the ultimate recovery of 
the child is concerned, but also as to its immediately 
perilous condition. 

2. Partial convulsions preceding general convulsions, 
and possibly continuing in the interval, suggest serious 
brain lesions of the cortex, and speak against the ultimate 
complete recovery of the patient; partial convulsions, 
however, may occur from non-organic causes. 

3. Severe general convulsions recurring at intervals 
without apparent exciting causes, especially if the 
patient has inherited a strongly neurotic temperament, 
should make one apprehensive that the child's predispo- 
sition to convulsive disorders is so great that epilepsy 
may develop. 

4. Convulsions occurring after traumatic injury to 
the head are not infrequently followed by true epilepsy 
or serious structural diseases of the brain. 



I$0 NEUROTIC DISORDERS OF CHILDHOOD 

5. Convulsions characterized by profound cyanosis 
and spasmodic breathing may produce such dangerous 
complications as asphyxia and cortical cerebral hem- 
orrhage. 

6. Prolongation of convulsive seizures adds to the 
seriousness of the prognosis not only in the greater 
immediate danger to life, but also in the fact that it 
indicates a more serious exciting cause which may 
threaten the future welfare of the child. 

7. To make an early definite prognosis is unwise 
because of its uncertainty. Even if one has an accurate 
knowledge of prognostic indications, a careful study of 
an infant that has but just recovered from its first con- 
vulsive seizure will not furnish the data for a safe prog- 
nosis. At this time the prognosis should be provisional, 
awaiting further developments to determine the causes 
which have produced, or the results which may follow, 
the convulsive seizure, since, after all, the character of 
the disease which produces the convulsion is the most 
important factor in prognosis. Pertussis and advanced 
rachitis, however, are among the grave etiological 
factors which may be determined or excluded at once. 

DIAGNOSIS 

The diagnosis in eclampsia comprehends not alone the 
fact that the child has convulsions, but also the character 
and cause of the convulsions. 

The diagnosis of convulsions is easily made, and is 
rarely if ever mistaken for any other syndrome, and the 
differential diagnosis as to the characteristics of indi- 
vidual convulsions has been sufficiently dwelt upon under 



ECLAMPSIA IN INFANTS AND CHILDREN 15 1 

Prognosis. There yet remains, however, something to 
be said on the importance of determining the cause of 
the convulsion, since upon this phase of the diagnosis 
depends all rational treatment. 

It may aid us in making the differential diagnosis of 
the disease or diseases responsible for the convulsive 
seizure to remember that all eclampsias in young children 
may be placed in one of the four following groups, named 
in order of their etiological importance: 

1. Those produced by acute systemic intoxications 
from bacterial toxins, as in the acute infections, espe- 
cially those from the intestinal tract, or from auto- 
toxins, as in uraemia. 

2. Those produced by chronic malnutrition (rachitis, 
etc.), or powerful hereditary factors (feeble inhibi- 
tion, etc.), plus some slight exciting causes, such as 
fright, teething, or undigested food. 

3. Those produced by organic diseases of the nervous 
system, such as cerebral hemorrhage and meningitis. 

4. Those produced by an epilepsy, with no apparent 
anatomical basis. 

In determining to which of these four groups the 
eclampsia belongs, one must make a comprehensive study 
of the individual case, including age, hereditary ten- 
dencies, previous condition, character of convulsions, 
surrounding circumstances, and especially all accessory 
symptoms pointing to the nature of the present illness. 

Since systemic intoxications are by far the most 
important of the etiological factors, a careful study 
should be made of the child's present and past intestinal 
condition. Intestinal fermentation and disease of the 



152 NEUROTIC DISORDERS OF CHILDHOOD 

digestive tract are most important. Symptoms of the 
specific infectious diseases should be looked for and 
the urine must always be examined. 

Failing to find indications pointing to acute systemic 
intoxication, the infant should be examined for rachitis 
and other forms of malnutrition, and its hereditary 
tendencies should be investigated on the suspicion that 
some slight exciting factor, aided by these powerful pre- 
disposing factors, may have been the cause of the 
convulsions. 

Failing to discover a satisfactory explanation for the 
convulsive seizures, organic disease of the nervous sys- 
tem should be suspected. If the convulsions occur during 
the first few days of life, cerebral hemorrhage is a proba- 
ble cause; but if the convulsions occur later, meningitis 
or other organic nervous diseases may be suspected. 

Lastly, no other exciting cause being apparent, epilepsy 
may be suspected in those cases where the convulsions 
have been repeated from time to time without apparent 
cause. 

TREATMENT 

In the majority of instances convulsions are self- 
limited, and last such a short time that the physician is 
not called upon to resort to any very active measures 
to control the convulsive movements. In these milder 
cases his energies must be chiefly directed to preventing 
a recurrence of the convulsive attack. 

It should be remembered, however, that in not a small 
percentage of the cases the convulsion itself is a source 
of danger, not only to life, but also to the subsequent 
well-being of the child, and that the longer the convulsion 



ECLAMPSIA IN INFANTS AND CHILDREN 153 

lasts, the greater are these dangers. It is the all- 
important duty, therefore, of the physician to terminate 
the convulsion as soon as possible, regardless of its 
cause. This may be done by inhalations of chloroform. 
The convulsive movements quickly disappear when a 
few drops of chloroform are placed upon a handkerchief 
and held to the child's nose. The administration of 
chloroform may be repeated at any time for the purpose 
of cutting short the return of convulsive movements, 
and the chloroform treatment is to be continued until 
the convulsive movements cease or have been brought 
under the control of other remedies. 

As soon as the convulsions have subsided under the 
first inhalations of chloroform the child is placed in a 
bath, the temperature of which will depend upon a num- 
ber of conditions. If the child have high fever, begin 
with a lukewarm bath and cool down to 8o° F. This not 
only reduces the body temperature, but exerts a soothing 
and tonic effect upon the nervous system. If, however, 
the patient be a very young or a very delicate infant, 
the bath is not to be cooled below 90 ° or 95 ° F. Some 
writers deprecate the efficiency of the bath in the treat- 
ment of convulsions; for my own part, I am, with the 
laity, a firm believer in the warm-bath treatment of con- 
vulsions in infants and children. It reduces fever, pro- 
motes the action of the skin and kidneys, and exercises a 
sedative and tonic influence upon the nervous system, 
and for these reasons it justly holds a high place in the 
routine treatment of eclampsia. 

Immediately the child is taken from the bath, an ice- 
cap should be applied to the head. This application 



154 NEUROTIC DISORDERS OF CHILDHOOD 

of cold to the head helps to keep down the temperature 
and acts as a sedative to the nervous system. The bath 
and ice-cap are to be used in the subsequent treatment of 
the case if high fever and nervous symptoms demand 
their use. 

A cathartic should be given as soon as possible in the 
treatment of infantile convulsions, regardless of their 
cause. The selection of the cathartic will depend upon 
the condition of the child's stomach; castor-oil is to be 
preferred if the stomach will retain it; if not, calomel 
is to be given in quarter of a grain doses every half- 
hour, until one or one and a half grains are given, accord- 
ing to the age of the child. The importance of the 
cathartic in the treatment of infantile convulsions does 
not depend wholly upon the fact that gastro-intestinal 
toxaemia is the most important etiological factor of con- 
vulsions, for, even in those cases which have their origin 
entirely apart from the intestinal tract, it is important 
in the treatment of the case that this canal be unloaded 
to prepare for the special dietetic treatment that is neces- 
sary in the subsequent management of almost all of these 
cases. 

A high rectal enema of a pint or more of physiological 
salt solution should be given immediately or very soon 
after removing the child from the bath. The object of 
this is to unload and irrigate the large intestine, so as to 
remove any possible source of irritation and prepare it 
to receive medicines which it may not be possible to 
give by the mouth. 

Chloral hydrate is the best and safest of all remedies 
used for the control of convulsive movements. It should 



ECLAMPSIA IN INFANTS AND CHILDREN 155 

be given dissolved in starch water by high rectal enema 
half an hour after the lower bowel has been washed out. 
The dose for a child of six months is five grains, and 
for a child of two years, ten grains. If the chloral be 
given, however, by the mouth, these doses are to be cut 
in half. In the beginning of the treatment it is advisa- 
ble to give the chloral by rectum rather than by mouth, 
even if the child can swallow, since it is most important 
that the cathartic which has been given should be re- 
tained. It is wise, therefore, not to risk upsetting the 
stomach either with food, stimulants, or medicines until 
the cathartic has acted. If the choral is retained by 
rectum for half an hour, and the convulsive movements 
are under control, the physician may safely leave the 
case for the time being in the hands of a competent 
nurse, with directions that the chloral injections be 
repeated in one or two hours, if necessary. After twelve 
or twenty-four hours the child is, as a rule, able to take 
by the mouth small doses of chloral combined with four 
or five grain doses of bromide of potash. It is not 
necessary, however, to continue this sedative treatment 
for any great length of time, as thirty-six hours usually 
suffices for the removal of all indications for sedative 
treatment. 

Morphine is the most certain of all the remedies we 
possess for the control of convulsions. A remedy, how- 
ever, which acts so powerfully must be used cautiously 
and in the proper dosage, and only when the other 
measures above outlined have failed to control the con- 
vulsive movements. 

In not a few instances the chloral is not retained by 



I56 NEUROTIC DISORDERS OF CHILDHOOD 

the rectum. In others the eclampsia may be so severe 
that the chloral fails to act. In such instances the child 
may have to be kept constantly under the influence of 
chloroform to control the convulsions. In these cases 
morphine is the safest remedy. It should be given hypo- 
dermically, in doses varying from a fiftieth of a grain, 
for a child six months of age, to a twentieth of a grain, 
for a child two years of age. These doses are perfectly 
safe, and they act specifically in the control of convul- 
sive movements. The dose may be repeated in an hour, 
and thereafter as necessary. It is rarely necessary, how- 
ever, to give more than one injection of morphine. After 
this, as a rule, the convulsions may be controlled by 
the other remedies above named. If in very severe 
eclampsia which requires morphine for the control of 
the convulsive symptoms, a prolonged period of coma 
or unconsciousness should follow the use of the mor- 
phine, it is advisable, especially in older children, to resort 
to venesection, followed by the injection into the vein, 
or subcutaneous tissues, of half a pint or more of sterile 
normal salt solution. This treatment, especially in 
ursemic poisoning, is frequently followed by a return 
of the child to consciousness. 

Absolute quiet for the nervous system and rest for 
the stomach are necessary during the first few hours, 
in the treatment of eclampsia. Food and stimulants by 
the mouth should be avoided until the intestinal canal 
has been unloaded. If, during this time, the child's 
condition demand stimulation, a rectal or subcutaneous 
injection of normal salt solution is the most effective 
remedy we have. 



ECLAMPSIA IN INFANTS AND CHILDREN 1 57 

During the early treatment of the case, following the 
control of the eclampsia, the child may be allowed water, 
barley water, or weak beef broth, provided it craves 
something to drink. 

After the cathartic has acted, and the cause of the 
eclampsia has been ascertained, the case is to be treated 
with reference to the control of the disease which caused 
the convulsion. If the trouble be of intestinal origin, 
as is the rule, then a period of careful feeding must fol- 
low. If nutritional disorder is an underlying cause, then 
the treatment must be directed towards the cure of the 
special form of malnutrition which is present. If the 
eclampsia be due to organic disease of the nervous sys- 
tem, the subsequent history of the case must determine 
the treatment of the existing disease. 



CHAPTER XII 

LARYNGISMUS STRIDULUS 

Synonyms. — Cerebral croup, child-crowing, inward 
spasms. 

Definition. — -Laryngismus stridulus is a reflex neurosis 
rarely observed outside of foundling hospitals and simi- 
lar institutions for the care of infants. It is characterized 
by spasm of respiratory muscles and especially of the 
adductor muscles of the larynx, which results in a sudden 
closure of the glottis, with a temporary shutting off of 
air from the lungs. 

ETIOLOGY 

Rachitis is by far the most important etiological factor 
in the production of this syndrome. All observers are 
agreed that there is a close relationship between rachitis 
and laryngismus stridulus. 

Kassowitz found in three hundred and seventy cases 
well-marked evidences of rachitis in all but one, and in 
87 per cent, of these cases he found a well-marked crani- 
otabes. Other writers, among them Jacobi, have called 
attention to the relationship of craniotabes to lar- 
yngismus stridulus. 

While the close association of rachitis, craniotabes, and 
laryngismus stridulus is recognized by all writers, it is 

158 



LARYNGISMUS STRIDULUS 1 59 

not at all certain that craniotabes or any other one mani- 
festation of rachitis is directly responsible for the spasm 
of the glottis. 

This symptom group is more especially associated with 
the acute advanced form of rachitis in which craniotabes 
is so common, and in which there is also a more marked 
irritability of the nervous centers than can be found in 
any other form of malnutrition occurring in infancy. This 
extreme excitability of the nervous centers, which makes 
it possible for slight. reflex factors to bring on a spasm 
of the glottis, is the all-important etiological factor of 
laryngismus stridulus. 

Lymph node tuberculosis producing a profound mal- 
nutrition and irritability of nerve centers may also be an 
etiological factor in the production of this syndrome. 
It may be associated with rachitis or with other forms of 
malnutrition in producing the irritability of the nervous 
centers, which is the underlying cause of this symptom 
group. 

Enlarged lymph nodes pressing on the recurrent laryn- 
geal nerve may also be an exciting cause of the 
paroxysm. 

The malnutrition produced by hereditary syphilis in 
premature infants, as well as the malnutritions produced 
by long-continued gastro-enteritis, may also bring about 
an irritability of the nervous centers which predisposes 
the infant to laryngeal spasm. 

Clinicians in studying the malnutritions associated 
with laryngismus stridulus may easily overlook a con- 
cealed tuberculosis or hereditary syphilis and report only 
the presence of certain rachitic symptoms, which may or 



l60 NEUROTIC DISORDERS OF CHILDHOOD 

may not explain the full character of the malnutrition. 
I do not wish to convey the opinion that rachitis is not the 
most important factor in producing laryngismus strid- 
ulus, but I do wish to insist that there are other forms 
of chronic malnutrition which are not uncommonly as- 
sociated with this disease. 

Age. — Laryngismus stridulus occurs as a rule between 
the sixth and the eighteenth month, just at, the period 
of life when rachitis, lymph node tuberculosis, hered- 
itary syphilis, and gastro-intestinal diseases are most 
common, and when these diseases produce the most 
extreme irritability of the nervous system. This is also 
the period in the life of the child when, on account of 
the lack of inhibition, the convulsive neuroses are most 
common. 

Season. — This symptom group occurs most commonly 
during the months of January, February, and March. 
These are the months during which infants are most 
commonly confined to hot, illy-ventilated rooms, and it 
is during these months that bad air, absence of sunlight, 
and bad hygiene contribute to the malnutritions above 
noted. 

Reflex Factors. — Among the reflex causes of laryn- 
gismus stridulus may be menti'oned stomach indigestion 
acting through the vagus, enlarged lymph nodes acting 
through the recurrent laryngeal nerve. It is also possi- 
ble that mucus or foreign substances which may acci- 
dentally drop into the larynx may excite a paroxysm. 
The cutting of a tooth, fright, anger, enlarged tonsils, 
adenoids, and nasal irritation have also been mentioned 
as exciting causes. 



LARYNGISMUS STRIDULUS ,l6l 



SYMPTOMS 



A nervous child suffering- from some profound mal- 
nutrition may, with little or no warning, be seized in 
the early hours of the night with a spasm of the glottis, 
the adductor muscles playing the most important role 
in this spasm. The closure of the glottis completely 
shuts off inspiration. As the glottis is closing the child 
sometimes in its struggles gives vent to a strident noise 
produced by the rushing in of air before the stricture 
of the glottis is complete. With the shutting off of air 
the child struggles for breath, and its face soon becomes 
cyanotic, the head is thrown back, convulsive movements 
of the diaphragm occur, the body stiffens, and the child's 
life seems in imminent danger, when suddenly a loud 
crowing inspiration announces the fact that the spasm 
has relaxed and all immediate danger is over. It is 
the strident crowing sound that marks the close of the 
paroxysm which characterizes the symptom group and 
gives it its name. 

Following this strident inspiration the child breathes 
rapidly, is greatly excited, cries and frets, and finally 
falls asleep, possibly to be awakened some hours later 
with a second attack. 

The spasm of the glottis which produces these par- 
oxysms lasts only twenty or thirty seconds; if it lasts 
longer the child is in- great danger from asphyxia or 
general convulsions. 

Second and third attacks almost always occur within a 
few hours after the first attack, and in severe cases the 



1 62 NEUROTIC DISORDERS OF CHILDHOOD 

child may have a dozen or more paroxysms in twenty- 
four hours. 

Convulsive movements of the diaphragm and other 
muscles of respiration are, as a rule, a part of the attack. 

Carpo-pedal spasm, which is one of the classical symp- 
toms of tetany, is so commonly associated with laryn- 
gismus stridulus that some writers, among them Cheadle, 
believe the two conditions to be the same. In about 
one-half the cases of laryngismus stridulus the fingers 
and toes are spasmodically flexed, just as they are in 
tetany, but otherwise the two syndromes differ widely. 

Eclampsia occurs in about one-third of the cases, the 
general convulsions supervening as the laryngeal spasm 
relaxes. 

An attack of laryngismus stridulus may occur at any 
time during the day or night, but the first attack of the 
series most commonly occurs during the most profound 
sleep in the early hours of the night. 

Holding the breath spells, which occur in older 
children, are closely allied to but not identical with 
laryngismus stridulus. In this condition the spasm of 
the larynx is usually brought on by a fit of anger. 

Spasms of the larynx occur also in acute laryngitis, 
whooping cough, and other diseases, but the clinical 
pictures they produce are quite different from that of 
laryngismus stridulus. 

PROGNOSIS 

Prognosis is good so far as the paroxysm is concerned, 
and if the underlying malnutrition can be successfully 
treated, then the prognosis, so far as ultimate recovery, 



LARYNGISMUS STRIDULUS 1 63 

is also good. Some of the more severe cases die from 
asphyxia or general convulsions. 

TREATMENT 

Treatment of the Attack. — The child should be taken 
up and cold water dashed into the face, or cold wet towels 
applied to the chest. If this does not relieve the parox- 
ysm, chloroform may be given by inhalation. In the 
vast majority of instances, however, the physician never 
has an opportunity to personally supervise the treatment 
of the attack. After one attack has occurred, however, 
he may leave directions that subsequent attacks are to 
be treated with cold water and chloroform. 

Prevention of the Attack. — For the first twenty-four 
hours the child is to be kept somewhat under the in- 
fluence of chloral, one or two grains every two or three 
hours. After the first twenty-four hours the bromides 
may be used; strontium bromide in three- to five-grain 
doses every four hours is to be preferred. 

Treatment of the Underlying Causative Condition. — 
This is the all-important part of the treatment, and should 
be followed up until complete recovery takes place. To 
accomplish this may require years. 

The special treatment indicated will depend entirely 
upon the character of the underlying malnutrition, but 
the most important part of that treatment will be dietetic 
and hygienic. The infant must have a carefully selected 
diet suited to its age and digestive capacity. It must 
also live in the open air and sunlight as much as possible. 
Cod-liver oil and other tonics may enter into the treat- 
ment. If the child has any disease of the naso-pharynx 



164 NEUROTIC DISORDERS OF CHILDHOOD 

or throat, or any other source of reflex irritation, these 
conditions must be treated and removed. 

The paroxysm of laryngismus stridulus may indirectly 
be instrumental in saving the life of the child, in that 
the profound malnutrition from which the infant is suf- 
fering is thus brought to the attention of the physician, 
who recognizes the importance of the underlying causes 
which have produced this alarming local spasm. 









CHAPTER XIII 

TETANY— IN CHILDHOOD 

Tetany is a neurosis characterized by tonic contrac- 
tures of muscles. These contractures may be intermit- 
tent, but as a rule they are persistent and subject to 
exacerbations at irregular intervals. The favorite site 
for these contractures is in the extremities; the muscles 
of the trunk, neck, and face may also be affected. 

ETIOLOGY AND PATHOLOGY 

Tetany occurs with far greater frequency in Europe 
than in this country. The consensus of opinion is that 
tetany is comparatively a rare disease in America. The 
epidemic form of the disease has not been noted here. 
Koplik says that the disease is not a rare one in New 
York. He has observed in his clinic a number of cases 
yearly. They appear in groups in the early spring 
months. 

Holt seldom sees more than four or five cases a year 
in a large hospital service in New York. Morse says 
the disease is a very unusual one in Boston, as shown 
by the statistics of the Medical Out-Patient Department 
of the Infants' Hospital, where 71 14 cases of disease 
were treated during the years 1896 and 1897, and among 
them was one case of tetany. In my own experience 

165 



1 66 NEUROTIC DISORDERS OF CHILDHOOD 

in the Cincinnati Hospital the disease is rare. In the 
average not more than one case occurs in this institution 
in a year. 

Griffith found that 72 cases (some of these doubtful) 
had been reported in American medical literature up to 
1894, and Morse, from 1894 to 1897, inclusive, found 
13 additional cases; while Griffith himself reports 5 
cases, and Morse 6. The reported cases do not give 
a very accurate estimate of the number of cases that 
actually occur, yet these figures justify the conclusion 
that tetany is a rather rare disease in America, and that 
in this country it occurs perhaps much more frequently 
in New York than elsewhere. 

Age. — Tetany may occur at any age, but it is much 
more frequent in infancy About 50 per cent, of the 
reported cases are under two years of age. Of the 95 
cases collected and reported by Griffith and Morse, 38 
were under one year of age, 8 were in the second year 
of life, 15 were between two years of age and puberty, 
and 34 above puberty. From this it appears that in 
America tetany is vastly more common in the first year 
of life than it is at any other period, two-fifths of all the 
reported cases being under one year of age. During the 
second year the disease is much less common than during 
the first year, yet it is still much more frequently observed 
during this period than in any subsequent year of the 
life of the individual. After the fourth year cases occur 
more frequently about the period of puberty than at any 
other time. 

The study of tetany in childhood is therefore largely 
a study of this disease as it occurs during the first year 



TETANY — IN CHILDHOOD 1 67 

of life, and the reasons for its more common occurrence 
during this period are found in the facts that gastro- 
intestinal diseases, rachitis, and other forms of severe 
malnutrition are most common at this time. 

The changes in the nervous system which produce the 
syndrome of tetany are not known, and for this reason 
it is classed as a neurosis. We do know, however, that 
whatever may be the character of these changes, they 
are temporary, since the great majority of cases of tetany 
terminate in complete recovery. Among the lesions of 
the nervous system which have been found in patients 
who have died during an attack of tetany are hydro- 
cephalus, hyperemia and oedema of the brain, and 
hyperemia; and a slight degree of poliomyelitis of the 
cord, especially the cervical portion, in which the motor 
cells of the anterior horns may show changes not unlike 
those noted under " fatigue " changes in the chapter on 
Reflex Irritation. These changes are not characteristic, 
neither are they constant. Many observers have failed 
to find anything noteworthy in the nervous system, and 
such changes as those above recorded may in large part 
be due to the long-continued action of toxins on the 
nerve centers. 

In the present state of our knowledge the action of 
toxins on the nerve centers is the most plausible theory 
of the production of the syndrome of tetany as it occurs 
in the young infant. It is probable, however, that the 
mechanism of the production of this syndrome is not 
always the same. Some of the cases of tetany occurring 
in the adult cannot be explained in this way. The epi- 
demic form of this disease which has been described, 



1 68 NEUROTIC DISORDERS OF CHILDHOOD 

especially by French writers, lends support to its toxic 
origin. 

Gastro-intestinal toxaemia is perhaps the most impor- 
tant etiological factor in producing infantile tetany. 
Gastro-intestinal disturbances are present in nearly every 
case occurring during the first two years of life, and even 
in the adult dilatation of the stomach and intestinal 
disease are spoken of as causal conditions. In about 
75 per cent, of all cases of tetany, including the adult 
cases, gastro-intestinal disturbances are present. 

Gastro-intestinal disease, occurring during the first 
two years of life, not only subjects the nervous system 
to constant irritation and poisoning by intestinal toxins, 
but it also produces a general profound malnutrition, 
which interferes with the development and increases the 
instability of the infantile nervous system. 

Rachitis. — More or less marked evidences of rachitis 
are found in nearly all infants suffering from tetany. 
The rachitis, however, in these cases is perhaps a phase 
of the malnutrition which has been produced by the 
gastro-intestinal disease and the character of the feeding 
which this disease has led up to. The rachitis associated 
with tetany is not commonly of a very severe type, and 
in this particular it differs from laryngismus strid- 
ulus. 

Rachitis, however, must be noted as one of the most 
important etiological factors of tetany, and it matters 
little whether or not we consider it a secondary mal- 
nutrition resulting from intestinal disorders. Other 
acute infections beside those of the intestinal canal may 
be responsible for the production of tetany. Gases have 



TETANY — IN CHILDHOOD 1 69 

been observed to follow measles, typhoid fever, 
rheumatism, and pertussis. 

Season. — Most of the cases occur during the winter 
and spring, when the infant living in tenement houses 
and foundling asylums has been housed and subjected 
to the influences of bad air, absence of sunlight, and 
other unhygienic conditions which aggravate the more 
important causative factors above noted. 

Sex. — In all the statistics there is a slight preponder- 
ance of males, the proportion being about as 5:4. It is 
a little difficult to understand why a male infant should 
be more susceptible to this disease than a female, since 
females, as a rule, are more susceptible to neurotic 
disease. The explanation, however, may probably be 
found in the fact that balanitis and adherent prepuce are 
important reflex factors in developing the disease in the 
male child. Later in life girls are more susceptible than 
boys. This is probably due to the reflex influence of 
menstruation. 

Reflex Factors. — It is probable that reflex factors, 
pure and simple, play a very unimportant role in the 
etiology of tetany. It must be remembered, however, 
that when the nervous system of the young infant has 
been placed in a state of extreme irritability by mal- 
nutrition and the action of toxins, it requires a minimum 
reflex excitant to produce rather profound nervous 
symptoms. Under conditions such as these one can 
understand how foreign bodies, worms, and undigested 
food in the intestinal canal, or adherent prepuce and 
adenoid growths, may be factors sufficient to touch off 
a paroxysm of tetany. 



170 NEUROTIC DISORDERS OF CHILDHOOD 

The epidemic form of this disease, which apparently 
does not occur in this country, and the form of the 
disease which follows the removal of the thyroid gland, 
and the adult type of this disease, will not be discussed 
here. 

SYMPTOMATOLOGY 

The most characteristic symptoms of tetany are tonic 
muscular contractures, which occur in almost any part 
of the body; but the most common and characteristic 
locations for these contractures are in the forearms, 
hands, and feet, producing the characteristic carpo-pedal 
spasms. 

The positions assumed by the hands and feet during 
the spasm are characteristic : the fingers are flexed at the 
metacarpo-phalangeal joints, the phalanges are extended, 
and the thumb is drawn across the palm of the hand. 
In some instances the phalanges, instead of being ex- 
tended, are flexed over the thumb, as it crosses the palm 
of the hand. The wrist is sharply flexed on the arm, and 
the whole hand is drawn towards the ulnar side. In the 
more severe cases the forearms are flexed on the arms 
and pressed against the sides of the thorax. 

In moving the elbow the resistance is not so great or 
so painful as in moving the wrist. In milder cases the 
shoulder and elbow are freely movable, while the con- 
tractures of the wrist and hand are very strong. 

The pedal spasm usually accompanies the carpal 
spasm; the feet are extended, and the first phalanges of 
the toes are flexed, and the others extended. The foot 
is curved inward, and the tendo-Achilles is very tense. 



TETANY IN CHILDHOOD IJ I 

The knee and hip-joints are usually free, but in some 
cases the thighs are adducted. 

While these contractures are commonly confined to 
the forearm, hands, and feet, it is not uncommon in more 
severe cases, especially those under one year of age, to 
have contractures of muscles of the trunk and neck, 
producing opisthotonos and stiffening of the body. I 
have seen cases of this kind in which the infant's body 
remained rigid when lifted from the bed by placing one 
hand under the hips and the other under the occiput. In 
rare instances the muscles of the face and eyes are 
involved. 

A paroxysm of tetany may continue for a few days, 
or it may last for weeks, and during this time the mus- 
cular contractures are, as a rule, continuous. There may, 
however, be periods during the paroxysms in which there 
is a marked remission or even a short intermission of 
the spasm. When the paroxysm has subsided the child 
under proper treatment, as a rule, progresses slowly to 
a satisfactory recovery, and this may occur without 
relapses. In other cases, however, second and third 
attacks recur at variable intervals, weeks or months 
intervening. 

Pain, as a rule, accompanies the spasm, especially in 
the severe cases. It may be severe enough to cause the 
child to cry out. The pain is greatly increased by any 
attempt to move the contractured part. Stretching or 
pressing a contractured muscle will produce pain. There 
is no loss of consciousness in this disease, unless general 
convulsions supervene as a complication. While general 
convulsions are not so common in this disease as they 



172 NEUROTIC DISORDERS OF CHILDHOOD 

are in laryngismus stridulus, they may occur, producing 
one of the most dangerous complications. (Edema of 
the feet, ankles, and wrists may be present. 

Temperature. — There may be an elevation of two or 
three degrees. This fever, however, does not belong 
to the tetany as much as it does to the intestinal fermen- 
tation, which is nearly always present. When the 
intestinal condition is properly cared for, tetany is, as a 
rule, an afebrile disease. 

The increased irritability and excitability of periph- 
eral nerves which occurs in tetany is responsible for 
some of its most characteristic symptoms. The increased 
nerve and muscle irritability is noted in the increased 
electrical excitability of both nerves and muscles, with 
changes in their qualitative reaction to galvanism. It 
is also shown in the facial phenomenon known as 
" Chvostek's symptom," where spasm of the facial mus- 
cles is produced by percussing over the facial nerve, and 
by Trousseau's symptom. This remarkable observer 
noted that in patients suffering from tetany the spasm 
could be greatly exaggerated by pressure upon the large 
nerve trunks and arteries of the extremities. All of 
these phenomena, due to the increased excitability of 
the peripheral nerves, may be observed not alone during 
the acute paroxysm, but may be observed in some cases 
for a considerable time after the muscular contractions 
have disappeared. In such cases the contractures may 
be developed in the manner described by Chvostek and 
Trousseau. So long, therefore, as Trousseau's or 
Chvostek's symptoms can be elicited, and so long as 
there is an increased electrical excitability of the muscles, 



TETANY IN CHILDHOOD 173 

first noted by Erb, the patient is still to be considered 
as not thoroughly convalescent from the attack. It is 
only when all of these evidences of the irritability of 
peripheral nerves have disappeared that the patient is to 
be considered convalescent, but even then the danger of 
second and third attacks is not removed until the under- 
lying intestinal disease and malnutrition have been cured. 

DIFFERENTIAL DIAGNOSIS 

Tetany is to be differentiated from tetanus by the loca- 
tion of the contractures, and by their intermittency, and 
especially by the absence of trismus, which is one of 
the earliest and most characteristic symptoms of tetanus. 
Trousseau's, Erb's and Chvostek's symptoms are not 
present in tetanus. The age and previous history will 
also assist in the differential diagnosis. 

TREATMENT 

In beginning the treatment of a case of tetany it is 
absolutely necessary to give close attention to the intes- 
tinal canal; calomel, followed by castor oil, will serve 
the purpose of removing all sources of irritation from 
the intestine, and prepare the patient for the very careful 
dietetic treatment that is to follow. The child must 
be carefully fed with a view not only of correcting the 
existing malnutrition, but also preventing further intes- 
tinal intoxication. The feeding of the child is therefore 
the all-important part of the treatment. For the control 
of the spasm, chloral and bromides may be used in 



174 NEUROTIC DISORDERS OF CHILDHOOD 

moderate quantities for a short time only. These 
remedies are to be dispensed with as soon as possible, 
and only resorted to when the spasms are severe and 
painful. Luke-warm baths at intervals during the day 
will not only help in the relief of the spasm, but will 
benefit the intestinal condition. The child should be given 
sunlight and fresh air; these are almost as necessary in 
the treatment of this condition as they are in tubercu- 
losis. As the child improves, cod-liver oil and iron are 
of great value in overcoming the malnutrition produced 
by rachitis or other causes. A search should also be 
made for every possible cause of reflex irritation. The 
prepuce and rectum should be examined, and as the child 
convalesces the throat and nose should be inspected. 
The removal of such reflex factors may facilitate the 
child's ultimate recovery., 



CHAPTER XIV 

ENURESIS 

Incontinence of urine in children is a true neurosis, 
and is not, as a rule, due to muscular incompetency of 
the sphincter vesicae. It is commonly associated with 
other nervous symptoms, with anaemia, and with reflex 
irritation. This condition, like the other neuroses of 
childhood, commonly rests upon a tripod of etiological 
factors, viz. : First, irritable and unstable nerve centers, 
due to age and heredity; second, bad blood and conse- 
quent malnutrition ; third, reflex irritation. 

In many cases these three factors coexist. We may, 
however, have incontinence of urine without malnutrition 
or malnutrition without incontinence. We may also have 
incontinence without apparent reflex irritation, and very 
strong reflex excitation, even on the part of the genital or- 
gans, without incontinence. It is not wise, therefore, to 
assume that phimosis, vesical irritation, or some other 
reflex factor is the sole cause of enuresis, or that general 
malnutrition, in any individual case, is the sole cause of 
this condition; nor can it be said that a neurotic inheri- 
tance is alone sufficient to produce enuresis, since the 
great majority of neurotic children do not suffer from 
this condition. A rational inquiry, therefore, into the 
etiology of a case of enuresis must inquire into the pres- 
ence or absence of each of these factors and their rela- 
tive importance in producing this syndrome. In order 

175 



I/O NEUROTIC DISORDERS OF CHILDHOOD 

to do this it is necessary to keep in mind the nervous 
mechanism of micturition. 

The longitudinal and circular muscular fibers which 
by their contraction empty the bladder are enervated by 
sensory and motor nerves from the lumbar region of the 
cord, and the external sphincter, in the prostatic portion 
of the urethra, which by its contraction prevents the 
escape of urine from the bladder, is also enervated by 
sensory and motor nerves from the lumbar cord. Von 
Zeissl's researches on the innervation of the bladder 
give us a better understanding of this subject. He 
found that " the erector nerve " was not only the motor 
nerve of the muscular coat of the bladder, but that it 
carried inhibitory fibers to the sphincter vesicae, and 
that " the hypogastric nerves " carry motor fibers to 
the sphincter vesicae, and inhibitory fibers to the muscular 
coats of the bladder. These researches explain the man- 
ner in which reflex excitation may act in starting or 
checking the flow of urine. For example, a reflex car- 
ried to the proper center in the lumbar cord would, 
through the motor fibers of the erector nerve, contract 
the muscular coat of the bladder and, through the inhibi- 
tory fiber of the same nerve, relax the sphincter vesicae, 
and in this manner allow the urine, which is being ex- 
pelled by the contracting bladder, to pass without hin- 
drance through the relaxed sphincter vesicae. This is, 
indeed, a simple and beautiful mechanism that must be 
understood if we are to estimate the importance of 
various etiological factors in their play upon this mech- 
anism. Another important fact that should also be 
mentioned in this connection is that the urination center 



ENURESIS 177 

in the spinal cord is partly under the inhibitory control 
of higher centers, including the voluntary centers in the 
brain cortex. The act of urination is, for this reason, 
partly under control of the will. We will to urinate or 
not to urinate, and the message passes down to the centers 
in the lumbar cord where, by the mechanism just de- 
scribed, the reflex act is completed. 

From this sketch of the nervous mechanism of urina- 
tion it is evident that the etiological factors of inconti- 
nence of urine may also be divided, with reference to the 
manner of their action, into three classes : first, those that 
act upon the higher centers in the brain, diminishing their 
inhibitory control over the urination center in the lumbar 
cord ; second, those that act directly on the centers in the 
lumbar cord, making them more irritable and unstable, 
and in that way increasing their reflex excitability ; third, 
those that act by reflex irritation indirectly on the spinal 
centers, touching off the nervous impulses which produce 
urination. 

With this general introduction we are better prepared 
to consider the cooperation of these factors in producing 
incontinence of urine. 



GENERAL ETIOLOGY 

Predisposing Causes. — Age is a most important and 
little understood predisposing factor of incontinence of 
urine. We are greatly indebted to Clouston for his care- 
ful study of the relationship of neuroses of childhood to 
the rapid metabolism and growth of brain tissue during 
this period. In early life the nerve centers are more 



178 NEUROTIC DISORDERS OF CHILDHOOD 

excitable by reason of their immaturity, and the great 
metabolism of nerve tissue incident to its rapid growth 
and development increases the sensitiveness of the nerve 
centers and exaggerates reflex phenomena. This, for the 
most part, is a cause more or less active in all children, 
and is largely responsible for the prevalence of the neu- 
roses in early life. The importance of age as an etio- 
logical factor takes yet greater prominence when one 
remembers that there is, during childhood, a functional 
immaturity of the centers inhibiting reflex acts. In 
early infancy inhibition is so feebly developed that we 
have during the first year of life a normal incontinence 
of urine. During this time the urinary center in the 
spinal cord, being under little or no inhibitory restraint, 
is excited to action by such very slight reflex causes as 
a small quantity of urine in the bladder. As the child 
grows older the mechanism inhibiting reflex acts be- 
comes better developed, and, as a result, in the second 
year of life the normal incontinence of urine gradually 
disappears. Delayed development, however, or other 
pathological factors may continue the incontinence of 
urine into the third year of life. When this occurs, the 
condition is considered pathological. Enuresis may 
continue until relieved by treatment, or until the inhibi- 
tory centers are better developed, and the nervous 
mechanism which controls urination is more stable; 
this, as a rule, occurs before the seventh year, but it may 
continue into adult life. 

Heredity. — Nearly all children suffering from enuresis 
have a neurotic inheritance. A family history of enu- 
resis, hysteria, neurasthenia, chorea, and other neuroses 



ENURESIS 1 79 

is common. Two or three children in the same family 
may suffer from incontinence of urine. This inherited 
neurotic tendency is a very important etiological factor, 
and depends upon an hereditary feeble inhibition and 
general nervous irritability, which, under favoring con- 
ditions, may find expression in incontinence of urine. 

Direct Causes. — Chronic malnutritions are most im- 
portant factors of enuresis. They act by bringing about 
a malnourished condition of nerve centers, which not 
only increases the reflex irritability of the spinal centers, 
but also lessens the functional activity of the higher 
centers of the brain, in this way still further weakening 
the inhibitory control which these centers exercise on 
spinal centers. The causes of chronic malnutritions, 
therefore, may be classed among the direct causes of 
enuresis. The most important of these causes are tuber- 
culosis, enteritis, rheumatism, malaria and syphilis. Im- 
proper food and bad hygiene are contributing factors in 
all of these conditions. 

About one-half of the cases of incontinence of urine 
seen in dispensary practice in Cincinnati, Ohio, have a 
tubercular malnutrition. Intestinal, rheumatic, malarial, 
and syphilitic malnutritions are also common. There 
is a well-marked chronic anaemia in 80 per cent, of the 
cases of enuresis seen in dispensary practice, and the 
anaemia in these cases can, for the most part, be traced 
to one or more of the five diseases above named. Chronic 
malnutritions may, therefore, be classed as the most 
important of all the blood factors of incontinence of 
urine. 

Auto-intoxication is an important factor in producing 



180 NEUROTIC DISORDERS OF CHILDHOOD 

enuresis. The form of auto-intoxication which is most 
commonly associated with enuresis is that which occurs 
in the uric acid or gouty diathesis. Fothergill says: 
" Lithuria is a very common occurrence in children of 
the uric acid diathesis. . . . Wetting the bed at night 
has close relations with uric acid, and in all cases of noc- 
turnal incontinence the urine should be examined. In 
my experience, wetting the bed occurs mainly in two 
classes of children — in very bright, vivacious, neurotic 
little girls, and in comparatively dull and backward chil- 
dren of low nervous organization. In either case the 
uric acid present plays a part." 

It is my own opinion that the enuresis which occurs 
so commonly in gouty or lithsemic children is due, not 
only to the action of auto-toxins on the nervous system, 
but also to the irritation of the bladder and genital 
organs which occurs in this condition as a result of the 
concentration and increased acidity of the urine. 

Bacterial Intoxication. — Chronic intestinal intoxica- 
tion, which is usually bacterial in origin, may produce 
profound malnutrition, and in that way furnish a basis 
for the development of enuresis. The acute infectious 
diseases are sometimes followed by incontinence of urine. 
The chronic bacterial intoxications which are also potent 
in producing this syndrome have been spoken of above 
under " Chronic Malnutritions." 

Malformations of the genital tract may also be re- 
sponsible for incontinence of urine; and organic diseases 
of the brain or spinal cord may have as one of their 
symptoms incontinence of urine. But these conditions 
have nothing to do with the neurosis under consideration. 



ENURESIS t8l 

All of the direct causes above noted act by bringing 
about an increased irritability of the general nervous 
system, and decreasing the inhibitory control which the 
higher centers exercise over the lower. Usually, more 
than one of these causes are found to be cooperative in 
producing enuresis, and they are usually associated with 
some form of reflex irritation. 

Exciting Causes. — Some form of reflex irritation 
probably acts as an exciting cause in every case of incon- 
tinence of urine. But in perhaps one-half of these cases 
the causes of the reflex irritation are so unimportant 
that they cannot be found. In such cases the reflexes 
may be a distended bladder, or even a small quantity of 
urine in a slightly irritated bladder, or some other condi- 
tion that varies so slightly from the normal that it could 
only excite to action nervous centers made hypersensi- 
tive by one of the direct causes above mentioned. In 
other words, the reflex irritation is so unimportant that 
it can scarcely be spoken of as a real factor in producing 
the enuresis. 

In the other half the reflex factor is important; it 
can, as a rule, be located, and its removal in many cases 
is necessary to successful treatment. Even in those 
cases, however, in which the enuresis disappears on 
the removal of a reflex factor, it does not follow that 
the reflex was the sole or even the most important cause. 
Other factors, such as grave nutritional disturbances, may 
have coexisted with the reflex irritation and yet not be 
made manifest by the continuance of the enuresis after 
the reflex has been removed. If relapses are to be pre- 
vented and the patient, as well as the enuresis, is to be 



1 82 NEUROTIC DISORDERS OF CHILDHOOD 

treated, a careful search for other factors should be made, 
even if the enuresis disappears on the removal of the 
reflex irritation. 

On the other hand, if little or no improvement immedi- 
ately follows the removal of an apparently potent reflex 
factor, it does not follow that this factor was unim- 
portant, since while it may not have played an important 
role in touching off the urination center in the lumbar 
cord, it may have produced a general spinal irritability, 
involving the lumbar as well as other centers, which 
remains long after the reflex irritation has been removed. 
The effects of chronic reflex irritation on the spinal cord 
do not disappear at once on the removal of the reflex 
factor which produced them. They do, however, slowly 
disappear when these factors are removed. If the reflex 
irritation is strong and long-continued, it produces the 
condition of general spinal irritability described in the 
chapter on " Reflex Irritation/' The changes which 
take place in the spinal cord cells under long-continued 
reflex irritation bring about an irritability of the spinal 
centers which the removal of the reflex and time alone 
can cure. 

The reflexes which are most closely associated with 
enuresis have their origin, as a rule, in genital, vesical, 
or rectal irritations, such as phimosis, preputial adhe- 
sions, contractions or granulations in the meatus, polypi 
in the rectum, fissure of the anus, acid and irritating 
urine, cystitis, and contracted and intolerant bladder, and 
vaginitis. 

Reflex irritations having their origin in diseases of 
distant organs, such as the throat, nose, eye, and intestinal 



ENURESIS 183 

canal, are not infrequently associated with enuresis. Dis- 
eased adenoids are very commonly associated with 
enuresis. 

Habit. — It should be remembered that whatever may 
have been the important etiological factors in producing 
enuresis, the condition may continue even after these 
factors are apparently removed. The continuance of 
the enuresis under these conditions is due not alone to 
the spinal irritability which may persist, as we have 
noted above, but is also due to the habit which is formed 
in these cases of emptying the bladder when it contains 
but a small quantity of urine. This habit is apparently 
engrafted upon the nervous mechanism which controls 
urination. 

SYMPTOMS 

Enuresis in about 55 per cent, of the cases occurs only 
at night. About 40 per cent, are both noctural and di- 
urnal, and about 5 per cent, are diurnal only. Inconti- 
nence of urine may occur once or several times during the 
night. In other cases milder in character it occurs at 
irregular intervals, days or weeks intervening. Noc- 
turnal incontinence occurs most commonly soon after 
the child goes to bed. At this time sleep is most profound, 
and the brain fails to perceive the symptoms of vesical 
irritation from a full bladder, and the unconscious higher 
brain centers there fail to exercise inhibitory control 
over the urination centers in the spinal cord. 

Ordinary enuresis being a pure neurosis, and not due 
to paralysis or lack of development of sphincter muscles, 
does not have as one of its symptoms the dribbling of the 



184 NEUROTIC DISORDERS OF CHILDHOOD 

urine. On the other hand, the contraction of the bladder 
empties this organ as thoroughly as under normal con- 
ditions, but it responds so quickly to reflex irritation 
that the patient is not able to control even for a short time 
the discharge of urine. 

Cases of enuresis that have apparently yielded to suc- 
cessful treatment not uncommonly have relapses. Enure- 
sis is commonly self-limited, and even those cases which 
have not yielded to treatment get well, as a rule, before 
the child is seven years of age, the growth and develop- 
ment of the nervous system effecting a cure. In a few 
cases, however, the disease may continue into adult life 
and in those cases in which the condition is dependent 
upon an incurable organic disease it may continue 
indefinitely. 

The urine of patients suffering from enuresis may be 
concentrated and increased in acidity, or it may be of 
low specific gravity, alkaline in reaction, and greatly 
increased in quantity. Uric acid, urates, oxalates, and 
phosphates are commonly found in excess; occasionally 
mucus, pus, and albumin are found, indicating disease 
of the genito-urinary tract; sugar occurs in a few cases, 
apart from those of true diabetes. 

PROGNOSIS 

When the enuresis is a symptom of organic disease 
of the brain or cord or of some malformation of the 
genito-urinary organs, the prognosis will vary with the 
prognosis of the organic disease which produces it. In 
the ordinary enuresis of childhood, however, the prog- 
nosis as to ultimate recovery is absolutely good, and as to 



ENURESIS 185 

cure in a limited time is also fairly good, since these 
cases, as a rule, yield to careful systematic treatment 
within a period of from two to six months. 

TREATMENT 

In the treatment of no other neurosis of childhood is 
it of so much importance to remove every possible cause 
of reflex irritation that can be discovered. It is an abso- 
lute waste of time to begin medical or other treatment 
until a most careful search for reflex factors has been 
made. Phimosis when present can, as a rule, be relieved 
by stretching the prepuce; circumcision is to be advised 
only in those cases which do not yield to this treatment. 
There is no more common error in surgical practice than 
that of sacrificing the prepuce for simple contractions 
of this organ. Under dilatation the foreskin can be 
separated from the glands, breaking up the preputial 
adhesions and removing the smegna; the parts are then 
to be anointed with vaseline, and this process is to be 
repeated daily for a period of eight or ten days. This 
treatment is simpler and far more efficacious than cir- 
cumcision in the great majority of these cases. Adherent 
prepuce is the normal condition in the young child, and 
in my experience is to be found in almost every case 
that has not been previously treated. It is the retention 
of the smegma and the consequent low grade of ballanitis 
which this condition brings about that makes it patho- 
logical. At any rate, in every case of incontinence of 
urine this routine treatment pertaining to the hygiene 
of the genital organs should be followed. 

The intestinal canal throughout should receive careful 



1 86 NEUROTIC DISORDERS OF CHILDHOOD 

attention ; worms and undigested food are to be removed 
by proper medication; rectal irritation from polypi, fis- 
sure, pin worms, or other causes must be treated, and 
fermentations must be corrected and prevented by proper 
food and medication. A small meatus may demand nick- 
ing and stretching. Stone in the bladder, cystitis, 
vaginitis, or any other abnormal condition of the genito- 
urinary organs must receive appropriate treatment. 
Adenoids, which strangely enough are often associated 
with enuresis, must be removed. In short, all reflex irri- 
tations capable of producing an increased irritability of 
the nervous system, even though they come from distant 
organs like the eye, nose, or throat, must be removed 
before other treatment is instituted. 

General hygiene is most important in the treatment of 
enuresis. The child should be removed from all excite- 
ment and nervous strain, should be taken out of school, 
and, if possible, sent into the country, where it can lead a 
quiet outdoor life. Wherever the child is treated it is 
imperative that his nervous system should be carefully 
protected. He should go to sleep early and at a regular 
hour and be fed upon a diet carefully selected to suit 
the individual case. If the child be tuberculous or suf- 
fering from any other form of grave malnutrition, the 
diet should consist largely of meat, eggs, milk, and bread, 
with such additions as the age and digestive capacity 
of the child may suggest. If, however, he has inherited 
a gouty diathesis, or has lithsemic symptoms other than 
the enuresis, or if at times his urine is very acid or con- 
centrated, depositing urates on standing, then his diet 
is to be slightly different. Such a child is to be allowed 



ENURESIS 187 

milk, cereals, cooked fruits, potatoes, and other well- 
cooked vegetables, but meats and eggs are to be partaken 
of sparingly. In all cases of incontinence of urine, beef 
juice, beef tea, alcohol, coffee, tea, sweets, and pastry, as 
well as all foods that may be beyond the child's digestive 
capacity, are to be prohibited. 

The moral treatment in these cases is important. The 
child should neither be punished nor be threatened with 
punishment for the incontinence. If the child is old 
enough, he should be made to understand the importance 
of overcoming the habit by retaining his urine for as 
long a time as possible during the day, provided the case 
is not one of diurnal enuresis. If the child can be 
taught to thus accustom the bladder to hold considerable 
quantities of urine for some hours during the day, then 
the habit on the part of the bladder of discharging urine, 
when only partly filled, may not be carried over into the 
night. 

When the incontinence occurs at night the child should 
take as little water as possible after four o'clock in the 
afternoon, and in the worse cases should be awakened 
about an hour and a half after going to bed, so that the 
bladder may be emptied and thus avoid the unconscious 
discharge later on. 

The foot of the bed should be raised so that the child's 
shoulders will be lower than his hips. This may prevent 
the urine in a partially filled bladder from running down 
into its neck and starting the reflex which finds expres- 
sion in incontinence. 

Cold daily douches to the spine are indicated in well- 
selected cases due to long-continued chronic reflex irrita- 



1 88 NEUROTIC DISORDERS OF CHILDHOOD 

tion and not associated with profound nutritional 
changes. The cold douche acts as a tonic to the irritable 
cord in these cases, and not infrequently the enuresis 
rapidly disappears. 

Treatment of the Malnutrition. — The malnutrition 
which occurs in perhaps 50 per cent, of all cases of 
enuresis must be successfully treated before one can hope 
to cure the incontinence. If the malnutrition be due to 
concealed tuberculosis, as it so commonly is, iron, cod- 
liver oil, fresh air, and good food are indicated. If it be 
due to chronic malaria, quinine and arsenic are indicated. 
If it be due to hereditary syphilis, anti-syphilitic treat- 
ment is indicated. If it be due to chronic digestive dis- 
turbances, carefully selected diet, pure air, outdoor life, 
and appropriate medication are indicated. 

In the treatment of enuresis, after reflex factors have 
been searched for and removed, the next important step 
is the differential diagnosis of the type of malnutrition 
upon which this neurosis may rest. If one can suc- 
cessfully treat the malnutrition, the enuresis which in 
large part is dependent upon it will disappear. 

MEDICAL TREATMENT 

Belladonna is the one drug which all writers recom- 
mend in the treatment of enuresis, and is no doubt the 
most valuable. Belladonna, it should be remembered, 
is well borne by children, and to get the results the dose 
must be gradually increased until the enuresis is con- 
trolled, or until disagreeable physiological symptoms are 
produced. The dilatation of the pupils and the dryness 






ENURESIS 1 89 

of the throat will indicate when a maximum dose has 
been reached. 

For a child of six years, it is well to begin with a dose 
of three minims of the tincture, three times a day. After 
a day or two this is slowly increased a drop or two a 
day until physiological symptoms are produced, or until 
the child is taking 25 or 30 drops a day. Some authori- 
ties prefer atropin. Holt says : " A convenient method 
of administration is to use a solution of atropin, 1 grain 
to 2 ounces of water, of which one drop (1-1000 of a 
grain) may be given for each year of the child's age. 
For nocturnal incontinence this dose should at first be 
given at 4 and 10 p. m. After a few days at 4, 7, and 
10 p. M. Usually this may be gradually increased until 
double the quantity is given. A child of five years would 
then be taking 10 drops (1-100 of a grain) at each of 
the hours mentioned. I have rarely found it advisable 
to go above these doses." 

In cases that are benefited or controlled by the bella- 
donna treatment, this drug should be continued in smaller 
doses for months. The belladonna being excreted by 
the urine acts as a local anodyne to the genito-urinary 
tract, and it is believed that the benefit which is derived 
from its use is largely, if not wholly, due to this local 
action. By allaying the irritability of sensory nerves 
it diminishes the potency of reflexes coming from these 
organs and increases the tolerance of the bladder. The 
curative influences of belladonna are therefore probably 
indirect, in that it controls the enuresis until the under- 
lying conditions can be removed by the treatment pre- 
viously outlined. The belladonna treatment also helps 



I9O NEUROTIC DISORDERS OF CHILDHOOD 

to overcome the habit of frequent urination, which is 
such a potent factor in keeping up the incontinence when 
it has once been well established. The indications, there- 
fore, for this treatment continue long after the enuresis 
has been controlled, and greater success will follow the 
use of this drug if it be given over a long period of time. 

Alkalies are invaluable in the treatment of those cases 
dependent upon the lithaemic diathesis and having an 
excess of urates and acids in their urine. In such cases 
the belladonna is to be combined with benzoate of soda 
or bicarbonate of potash, and this prescription may be 
made more palatable by the addition of peppermint water 
and essence of pepsin. For a child of six years of age 
5 grains of either of these alkalies may be given after 
meals. It is perhaps better to prescribe the alkali and 
belladonna in separate bottles, giving them at the same 
time, but allowing for an increase of the belladonna with- 
out increasing the alkali. In this type of case also the 
constipation which is usually present is to be overcome 
by phosphate of soda, or sulphate of soda put up in pala- 
table solution. In older children effervescing carbonated 
waters may be used to cover the taste of these drugs. 
If the lithaemic condition is recognized and successfully 
treated, the enuresis will, as a rule, take care of itself. 

In very nervous hysterical children not of the lithaemic 
type, the bromide of potash may be used, combined with 
the belladonna treatment, to assist in getting control 
of the enuresis. The bromide treatment, however, is 
not to be continued for any length of time. 

Ergot is a drug highly spoken of by many writers, 
and must therefore be of value in the treatment of cer- 



ENURESIS 191 

tain cases of enuresis. I must confess, however, that I 
have not been impressed with its efficacy. Aromatic 
tincture of rhus in 5 to 10 drop doses three times a day 
is at times a very efficacious remedy and should be tried 
when the above treatment fails. 

Strychnine is another drug universally used and uni- 
versally commended by the very best writers in the treat- 
ment of certain cases of enuresis. I, however, believe 
that this drug is of little or no value, and in many cases 
is absolutely contra-indicated. I believe that its use 
originated in the belief that the incontinence of urine was 
due to a weakness rather than to a lack of proper innerva- 
tion of the sphincter muscles. The fact, however, that so 
many writers have used it apparently with good results 
would justify its further use in these cases. 

Electricity is another therapeutic measure in which 
I have little faith. In those cases which have yielded 
to faradism, when locally applied to the bladder and rec- 
tum, the result, I believe, was due to suggestion rather 
than to electricity. It should be stated, however, that 
the electrical treatment of enuresis has been very highly 
extolled by some writers, and that galvanism to the 
spine is perhaps of real value in these cases. 

Cathelin's method of epidural injections into the 
sacral canal between the periostium of the vertebras and 
the dura mater, of 10 to 25 cc. of sterile decinormal salt 
solution given in the average once in seven days, has 
recently been used with some success in the treatment of 
these cases. 



CHAPTER XV 

MIGRAINE 

Synonyms. — Megrim, sick headache, hemicrania. 

Definition. — Migraine is an auto or intestinal intoxi- 
cation which finds expression in recurrent self-limited 
attacks of severe paroxysmal headaches, usually uni- 
lateral, commonly accompanied by nausea, vomiting, ver- 
tigo, and visual phenomena, and followed by a profound 
sleep, from which the patient awakes free from pain. 

ETIOLOGY 

I. Predisposing Causes. — Age is an important pre- 
disposing factor; the majority of cases appear in late 
childhood or early adult life. Not a small percentage, 
however, begin between the fifth and the tenth year; in 
these cases occurring in early childhood the stomach 
symptoms are, as a rule, more pronounced and the hemi- 
crania less severe. Migraine once established does not, 
as a rule, spontaneously disappear until the fifth decade 
of life. The disappearance of migraine at this period 
is probably due to the arterio-sclerotic changes which 
occur rather early in individuals of this type. The hard 
arteries of the migrainous patient of fifty protect him 
from the vasomotor disturbances which are an essential 
part of the migrainous attack. In women the cessation 
of menstruation at or about the fiftieth year removes 

192 



MIGRAINE 193 

one of the most common of the exciting causes of mi- 
graine, and offers another explanation for its common 
disappearance at this time of life. 

Sex. — Migraine is, among the poor and uneducated, 
much more common in women than in men, the propor- 
tion being as four or five to one. Among the rich and 
refined, however, there is but a slight preponderance of 
females, and this is perhaps due to the influence of the 
menstrual function in precipitating these attacks. 

Season. — Migraine occurs more frequently during the 
winter than the summer months in the Middle and 
Northern States. This is probably a matter of diminished 
outdoor life, change of food, and decreased action of 
the skin. 

Heredity is by far the most important of the predis- 
posing factors. There is, as a rule, a history of direct 
migrainous inheritance, which may run back a number 
of generations ; or there may be a general neurotic inheri- 
tance, other members of the family having suffered from 
functional nervous diseases. A gouty inheritance is 
also commonly observed, and this may carry with it the 
history of a family tendency to functional disturbances 
of the liver, which manifests itself in so-called attacks 
of biliousness. 

Constipation, which is one of the most common etio- 
logical factors of migraine, is closely associated with the 
so-called bilious temperament. The hyper-fermentation 
of the intestinal contents which results from constipa- 
tion may produce intestinal toxins which an incompe- 
tent liver is not able to destroy. 

Occupation is a very important predisposing factor 



194 NEUROTIC DISORDERS OF CHILDHOOD 

and makes this disease very prevalent among the poor, 
because of their indoor life, lack of fresh air and sunlight. 
For this reason the disease is very common among factory 
girls and tenement house dwellers. It is also probable 
that unwholesome and improperly prepared food and the 
general ill-health of this class predispose them to mi- 
graine. The men among the poor, however, do not 
commonly suffer from this disease, because of the out- 
door life and great physical exercise incident to their 
occupations. Here we have an explanation for the fact 
that women suffer much more frequently from this dis- 
ease than men. Among the rich and refined, however, 
those leading a sedentary life and exposed to mental 
overwork and nerve excitement and commonly given to 
excesses in eating and drinking, we find the disease 
almost as common in men as it is in women. 

Food. — Excess of highly seasoned foods, coffee, alco- 
hol, meats, and sweets may predispose to migraine, 
probably through their influence on the functions of the 
liver and intestinal canal. While excesses in eating and 
drinking along the lines above indicated are especially 
harmful, it is important to note that it is the excess 
rather than the character of the food that produces the 
greatest harm. 

II. Direct Causes. — Toxins are responsible for the 
paroxysms of migraine; of this I think there can be 
little doubt. As to the exact nature and character of 
these toxins, and as to whether they are chiefly auto 
or intestinal, it is still a matter of great uncertainty, and 
upon these questions the medical profession is by no 
means agreed. It is my belief, however, that auto-toxins 



MIGRAINE 195 

play the most important role in producing migraine and 
that these toxins are produced by a faulty metabolism 
of albumins and lack of oxidation of the retrograde 
bodies, formed by the death and disintegration of the 
cellular elements of the body. The uric acid bodies, 
especially the xanthin bases, probably play the most im- 
portant role in this intoxication ; at any rate, auto-toxins 
closely associated in their formation, if not identical, with 
the uric acid bodies are at least partly responsible for 
the symptoms of migraine (see chapter on " Auto-intoxi- 
cations "). 

Intestinal toxins no doubt also play a role in the pro- 
duction of many cases of migraine, since the removal 
of constipation and resulting intestinal fermentation 
which are present in so many of these cases is ofttimes 
followed by a great amelioration of the symptoms (see 
chapter on " Intestinal Toxins "). 

Liver Incompetency. — The poisons which produce 
migraine, whether they be auto or intestinal in their 
origin, are under normal conditions largely destroyed 
or converted into harmless products by the liver. These 
poisons are therefore thrown into the general circula- 
tion by all conditions that diminish the functional 
capacity of that organ, such as indoor life and lack of 
exercise, and by all conditions that throw increased work 
upon the liver, such as excessive eating and alcohol and 
coffee drinking. The liver through its filtering function 
normally stands guard between the toxins of the in- 
testinal canal and the general circulation, and through its 
urea-forming function it converts ammonia and the purin 
bodies into harmless urea. These important functions 



I96 NEUROTIC DISORDERS OF CHILDHOOD 

of the liver protect against both auto and intestinal 
toxins, but under pathological conditions, either through 
a weakened functional capacity of the liver, inherited 
or acquired, or through excess of poisons produced, the 
liver is no longer able to destroy these poisons, and a 
periodic acute functional incompetency of this organ 
results, thereby throwing these poisons into the general 
circulation, producing an acute intoxication. Within 
twenty-four or thirty-six hours, these poisons being ex- 
creted and the liver having resumed its function, the 
attack of migraine is ended. 

It is my belief that under aggravated pathological 
conditions the liver may remain for a long time in a state 
of chronic partial incompetency, thus allowing a portion 
of these poisons to filter through into the general circu- 
lation, producing a state of either chronic auto or intes- 
tinal intoxication. In this condition the liver is com- 
monly enlarged, and the migrainous symptoms, while not 
so severe as in the paroxysmal attacks, are more or less 
constant, producing a neurasthenic condition. 

Action of Poisons. — The poisons which produce mi- 
graine commonly act through both the sensory and sym- 
pathetic nerves of a part, producing both pain and vaso- 
motor disturbances. In the young child the vasomotor 
disturbances are more marked and the poisons are 
more prone to act upon the sympathetic nerves of the 
stomach. 

In the adult, however, the sensory nerves of the head 
are commonly attacked, producing a severe hemicrania, 
and the vasomotor nerves of the same region are also 
acted upon, but the stomach disturbances are not so severe 



MlGRAINfi 197 

or so common as they are in the child. The points of 
attack which these poisons commonly select are the 
nerves, both vasomotor and sensory, of the head and of 
the stomach. It is probable that the vasomotor nerves 
are primarily attacked and the sensory disturbances are 
secondary. 

III. Exciting Causes. — Eye-strain due to errors of 
refraction and insufficiency of certain eye-muscles is one 
of the most common exciting causes of migraine. Cases 
of this character are relieved by the correction of the 
eye-strain. This, however, does not prove that the eye- 
strain was the sole cause of the recurring attacks. It 
does prove, however, that in some cases the exciting 
factors are so important that their removal greatly modi- 
fies the number and the severity of the paroxysmal 
attacks, notwithstanding the existence of certain toxic 
and predisposing factors. The removal of reflex factors, 
therefore, may lengthen the interval between, and modify 
the severity of, migrainous attacks, but headaches that are 
altogether cured by correcting eye-strain are reflex rather 
than migrainous in character. 

Diseases of the naso-pharynx and of the genito-urinary 
and pelvic organs are among the exciting causes of mi- 
graine. In females menstruation is probably the most 
important of all exciting causes; the headaches in these 
cases recur with great regularity at or near the menstrual 
period. It should be remembered, however, that all 
menstrual headaches are not migrainous in character. 

Fatigue, emotional excitement, overtaxation of the 
nervous system, and overwork at school are important 
exciting causes of migraine. 



I98 NEUROTIC DISORDERS OF CHILDHOOD 

Certain foods, such as acid fruits and acid wines, may 
in susceptible individuals be exciting causes, and di- 
gestive disturbances of any kind may precipitate an 
attack. 

SYMPTOMS 

The symptoms of a migrainous attack will vary with 
the part attacked, the nerves involved, the virulence and 
character of the poisons, and the age and physical con- 
dition of the patient. 

The attack is at times preceded by certain prodromes 
such as vertigo, tinnitus aurium, partial vision, bright 
and dark spots, and flashes of light before the eyes, 
transient aphasia, with a fullness about the head and a 
peculiar tingling or burning sensation in some portion 
of the body, which the individual by experience learns 
to interpret as the forerunner of an attack. Certain of 
these prodromes may continue for a number of hours, 
when the attack is ushered in by a headache, which 
is, as a rule, unilateral. The headache gradually in- 
creases in intensity, sometimes spreading to the opposite 
side. 

The pain is intense, throbbing in character, and con- 
tinues for a number of hours. It is increased by 
light, noise, or movement of the body. For these 
reasons the patient usually lies down in a quiet, dark 
place. 

Nausea, as a rule, occurs early in the attack, and in- 
creases in severity until actual vomiting occurs. The 
vomiting, which occurs some hours after the headache, 
usually marks the climax of the paroxysm, and from this 



MIGRAINE 199 

time the symptoms gradually abate. The vomited matter 
contains not only the food content of the stomach, but 
also bile, considerable mucus, and an excess of free HC1. 
The hyperchlorhydria which occurs during attacks of 
migraine is similar to that which occurs in recurrent 
vomiting. 

The pain in the head, which is a characteristic symp- 
tom of migraine in the adult, may be almost entirely 
absent in the young child, and the vomiting, which is 
rather a secondary symptom in the adult, may be the 
most pronounced symptom in the child. Frequent vomit- 
ing with constant nausea may continue for days, without 
any pronounced pain in the head, and in this condition 
we have the symptom group described as " recurrent 
vomiting " in the next chapter. In the older child and 
the adult, however, we not infrequently have the per- 
sistent vomiting and the severe headache combined. Pain 
in the stomach of great severity may at times take the 
place of pain in the head. I have seen cases of migraine 
go on for years, with the typical symptoms of hemicrania 
and vomiting, and then, without apparent cause, these 
attacks would be replaced by paroxysms, characterized 
by severe pain in the stomach, with nausea and vomiting, 
but with little or no pain in the head. 

During the paroxysm, when the pain is most severe, 
vasomotor disturbances are present; aphasia and vertigo 
may occur, and one side of the face may be pale and the 
other side show red spots on the cheek or ear. The 
flushing of the ear and side of the face may come and 
go during the attack, or may continue until the pain in 
the head has disappeared. These phenomena are more 



200 NEUROTIC DISORDERS OF CHILDHOOD 

marked on the side of the face which is the seat of the 
pain. 

Profound sleep, in some instances almost amounting 
to mild coma, which terminates the paroxysm of mi- 
graine, is one of its most characteristic symptoms. The 
attack may have gone on for twelve or twenty-four hours 
when the patient, yielding to the sensation of drowsi- 
ness, falls asleep, and six or eight hours later awakens 
free from pain. At times, following severe attacks of 
migraine, there will be a day during which there is a 
feeling of mental apathy and disability with partial 
aphasia, but even in cases of this kind the second day will 
find the patient entirely recovered and possessed of a 
keener mental acumen than he possessed before the at- 
tack. The storm seems to have cleared his mental 
horizon. 

The temperature in the adult is, as a rule, normal; in 
children, however, the temperature during the height 
of the paroxysms is commonly elevated from one to 
four degrees; later, following the sleep, the temperature 
may be subnormal. The pulse in the child is rapid and 
irregular; in the adult it is hard and variable, some- 
times slow and sometimes rapid. 

Attacks of migraine are self-limited and vary in dura- 
tion from a few hours to two or three days. Occa- 
sionally, however, we have aggravated pathological con- 
ditions, producing what may be described as chronic 
migraine. In these patients there is chronic dyspepsia 
and more or less continuous depression of spirits, with 
general nervous irritability and vague fears character- 
istic of the neurasthenic condition. More or less head- 



MIGRAINE 201 

ache may occur every day, with morning nausea, and this 
condition, if it continues, soon becomes a pronounced neu- 
rasthenia. Chronic migraine, however, is uncommon in 
childhood. 

Migraine does not, like epilepsy, lead to mental im- 
pairment. On the other hand, it may be said that chil- 
dren suffering from this condition are nearly all pre- 
cocious, and the precocity which is manifested early not 
uncommonly continues through life. At any rate, it is 
a matter of history that many of the greatest intellects 
that the world has produced have been sufferers from 
migraine. 

The paroxysms of migraine occur at regular or irregu- 
lar intervals. Now and then the paroxysms will be 
observed to recur at regular weekly, fortnightly, or 
monthly periods. The monthly interval is the most com- 
mon, since migraine occurs most frequently in women, 
and since the menstrual period is the most important 
exciting cause. The fortnightly interval is also common. 
In these cases we have the menstrual paroxysm occuring 
at or near the menstrual time, and the inter-menstrual 
paroxysm occuring half-way between. In many cases 
in women, however, the return of the paroxysm has noth- 
ing to do with the menstrual period, and the interval is 
quite as irregular with them as it is with men. In chil- 
dren the paroxysm has been observed to recur at weekly 
intervals. 

DIAGNOSIS 

One of the important points in differential diagnosis 
of migraine from other paroxysmal headaches is found 



202 NEUROTIC DISORDERS OF CHILDHOOD 

in the urine. The urine in migraine is high-colored, with 
high specific gravity, and contains an excess of the purin 
bodies, including uric acid and the xanthin bases. The 
increase, however, in the xanthin bases is much more 
marked than is the uric acid increase. The urine con- 
tains a diminished amount of urea and an excess of 
ammonia, which is probably excreted in combination 
with acids. The urine is increased in acidity and, in 
some instances, contains acetone and diacetic acid. 
Occasionally, especially in children and in those past 
middle life, a transient albuminuria accompanies the 
paroxysm. 

Apart from the urine, however, the differential diag- 
nosis of migraine is not difficult. Recurring hemicrania, 
associated with nausea and followed by sopor, are not 
characteristic of any other type of headache. It is only 
in cases of chronic migraine where these characteristic 
symptoms are more or less lost in the chronic character 
of the disease that one is likely to be mistaken. But 
even in such chronic cases the diagnosis may be made 
by the early history of typical attacks of migraine, which 
have gradually merged into the present chronic condi- 
tion. The hereditary predisposition and the vasomotor 
symptoms previously described will assist in establishing 
the diagnosis. 

PROGNOSIS 

As to Cure. — Many of these cases can be cured, and 
all of them can be relieved, by proper treatment; that is 
to say, the severity of the paroxysms may be diminished 
and the interval between their occurrence prolonged. 



MIGRAINE 203 

As to Complications. — The poisons which produce 
migraine are most potent factors in producing arterio- 
sclerosis. Arterial changes come on earlier in the 
migrainous individual, and, as has been previously said, 
these changes, by interfering with the elasticity of 
arteries, prevent vasomotor disturbances ; and in this 
way assist in terminating these paroxyms as age and 
arterio-sclerosis advance. These arterial changes, how- 
ever, predispose these patients in later life to cerebral 
hemorrhage and arterio-sclerosis of the kidney. If, 
therefore, we recognize in migraine an auto-intoxica- 
tion which may bring on a premature arterio-sclerosis, 
we can say that the prognosis, so far as life is concerned, 
in the untreated cases, is not the best, inasmuch as these 
patients are likely to die from cerebral hemorrhage or 
diseases of the kidney years before their allotted time. 

TREATMENT 

Treatment of Attack. — If large doses of benzoate of 
soda (60 grains) or bicarbonate of soda (teaspoonful) 
be given at the onset of prodromal symptoms, the mi- 
grainous attack may be aborted, or very much modified in 
severity ; with the soda it is advisable to give two or three 
grains of calomel. If desirable, the soda and calomel may 
be given in broken doses : twenty grains of bicarbonate of 
soda and one-half grain of calomel every hour for four 
doses. For children under ten years of age the soda in 
these prescriptions may be diminished one-half. If this 
treatment does not give relief, the following prescription 
is a safe, and, if given early in the attack, a very effica- 



204 NEUROTIC DISORDERS OF CHILDHOOD 

cious remedy; it will, however, be more effective if the 
patient on taking it lies down in a darkened room. 

Caffeinse citratse 2 grains 

Sodii salicylates (gaultheria) ....... 10 " 

Sodii bromidi 30 " 

Sig. — To be taken in half a glass of carbonated water (dose 
for an adult, half this dose for a child ten years of age). 

This powder when given as here directed is almost if 
not quite as efficacious as the coal-tar products in reliev- 
ing an on-coming headache ; it may be repeated at inter- 
vals with no untoward results. 

The use of the coal-tar products, especially acetanilid, 
for the relief of migrainous headaches is for the most part 
to be discouraged, since patients suffering from so chronic 
a disease attended with so much pain may, to their injury, 
prefer to resort to these remedies for relief during the at- 
tack rather than take the trouble to follow the preventive 
treatment presently to be outlined. There is little doubt 
that many migrainous patients are assisted on the 
road to chronic invalidism and neurasthenia by the fre- 
quent use of the headache powders (acetanilid) which are 
so widely advertised as harmless and curative. These 
powerful headache remedies if taken in large doses at 
short intervals weaken the heart and destroy red blood 
corpuscles, and thus, by interfering with elimination, in- 
crease the auto-intoxication from which the patient suf- 
fers. If, however, in individual cases it is thought ad- 
visable under proper restrictions to give the coal-tar pro- 
ducts for the relief of migrainous headaches, antipyrin is, 
in my opinion, the safest and most effective of these 



MIGRAINE 205 

preparations. It may be substituted for the sodium 
salicylate in the prescription above given. It is, however, 
rarely necessary to use these remedies in children under 
ten years of age. 

Hot fomentations to the forehead may assist the above 
remedies in giving relief from pain. 

Occasionally an attack of migraine may be so severe as 
to demand the use of morphine hypodermically. This 
remedy, as a rule, gives almost immediate relief, and is 
perfectly safe in the hands of the physician ; it is, however, 
very rarely indicated in children under ten years of age. 
The giving of morphine hypodermically for the relief of 
these headaches should never be intrusted to the patient, 
for fear of establishing the morphine habit. 

In the treatment of the attack in young children calo- 
mel and soda, followed by caffeine and bromide of potash, 
should for the most part be relied upon to relieve the head- 
ache. It is rarely necessary to use the coal-tar products, 
and never necessary to use morphine at this age. One or 
two hours following the calomel and soda a child six 
years of age may take one grain of citrated caffeine, and 
five grains of bromide of potash every hour or every half 
hour for three doses. If this treatment is commenced 
with the onset of premonitory symptoms, it usually suf- 
fices to relieve the attack. 

In the child the above remedies not infrequently pro- 
voke vomiting, which is, as a rule, a much more prominent 
symptom of the migrainous attack in the child than it is 
in the adult. This fact, however, does not contra-indi- 
cate the above line of treatment, since with the onset of 
vomiting the pain in the head generally becomes less in- 



206 NEUROTIC DISORDERS OF CHILDHOOD 

tense. At no age is vomiting coming on during the 
height of the migrainous attack to be considered an un- 
desirable symptom. This act serves the purpose of wash- 
ing out the stomach, and may, as a rule, be advanta- 
geously followed by another dose of bicarbonate of soda 
dissolved in a glass of carbonated water. 

The above line of treatment, which either aborts, short- 
ens, or modifies the severity of the migrainous attack, is 
very important, and its efficacy should be insisted upon. 
But in giving attention to this phase of the treatment it 
should be remembered that the true treatment of migraine 
is the interval treatment, which has for its object the re- 
lief of the underlying constitutional condition and the 
prevention of these attacks. These desiderata can, for 
the most part, be realized if the patient will conscientiously 
follow the medical, dietetic, and hygienic treatment below 
outlined. The importance of this treatment may be 
further insisted upon in that it may delay the premature 
arterio-sclerosis which results from the auto-intoxications 
that produce migraine. 

Preliminary Treatment. — In beginning the treatment 
of a case of migraine it is all-important that reflex fac- 
tors which may possibly play a role in producing the 
paroxysmal attacks should be searched for and, if 
possible, removed. Such reflex factors are most com- 
monly found in ocular defects producing eye-strain. The 
eye is, in fact, such an important source of reflex irrita- 
tion to the nerve centers that certain oculists assert that 
ocular defects are the most potent factors in producing 
migraine. Abnormal conditions of the nose and phar- 
ynx, such as adenoids and hypertrophies, also play a 



MIGRAINE 207 

most important role as reflex excitants of the nerve 
centers. 

Diseases of the pelvic organs, in many instances, are 
unquestionably etiologically related to migraine. Dis- 
eases of these organs may, by interfering with elimina- 
tion, by the formation of toxins, and by acting as a 
source of reflex irritation, increase the general nervous 
irritability of the patient, and in that way act as predispos- 
ing if not direct exciting causes of migraine. It is there- 
fore important in the early treatment of migraine that the 
physician should satisfy himself that eye-strain or some 
disease of the nose, throat, pelvic organs, or gastrointes- 
tinal canal are not important factors in producing the 
paroxysmal headaches from which the patient suffers. 

It is not an uncommon experience to have migrainous 
attacks almost disappear on the removal of some aggra- 
vated pathological condition which is causing intoxi- 
cation or reflex irritation of the nerve centers. This does 
not, however, prove that the toxin or the reflex is the sole 
factor in producing the migraine in these cases. It does 
prove, however, that these factors are so important that 
it would be folly to attempt the constitutional treatment 
of such cases without the removal of these factors. 

Migraine is, as I believe, a consitutional disease due to 
an auto-intoxication, and with this condition there may 
coexist a cause of reflex irritation to the nervous system 
so important that it is impossible to completely cure these 
cases without the removal of the reflex factors. 

Medical Treatment for Relief of Constitutional Condi- 
tion. — Since migraine is a chronic disease, and treatment 
must be continued over many months, it is absolutely 



208 NEUROTIC DISORDERS OF CHILDHOOD 

necessary for permanent success in the treatment of this 
condition that the medical treatment should be as simple 
and as palatable as possible. This is true of men, women, 
and children alike. The busy man cannot, as a rule, be 
prevailed upon to take over a long period of time three or 
four doses of medicine each day, and women and chil- 
dren, as a rule, after a few weeks of treatment prefer the 
disease to taking dose after dose of unpalatable medicine 
throughout an entire season. The keynote of success, 
therefore, in the treatment of migraine is in the simplicity 
and palatability of effective medication. To accomplish 
these desiderata, some ten years ago I devised a formula, 
which is here presented with such slight changes as time 
and experience have suggested: 

Sodii sulphatis (dry) 30 grains 

Sodii salicylates (from wintergreen) ... 10 " 

Magnesii sulphatis 50 " 

Lithii benzoatis 5 

Tincturae nucis vomica? 3 drops 

Aquae destil. to make 4 ounces 

M. S. — Take each morning. Dose for an adult. 

This prescription is made in large quantities by a reli- 
able pharmacist, and sent by him to a mineral water fac- 
tory to be put up in siphons and charged with carbonic 
acid. These siphons I prescribe under the name of 
" Siphon C," and direct my adult patients to take from 
one-quarter to one-half glass of this carbonated medicine 
each morning on arising, half an hour or more before 
breakfast. It is important that the dose should be so 
regulated as to produce a slightly laxative but not cathar- 
tic action. Only one dose of this medicine is given in 



MIGRAINE 209 

twenty-four hours, and after the patient is fairly under 
treatment this is commonly the only medicine used. Chil- 
dren over ten years of age can, as a rule, be induced to 
take this prescription, but under that age some substitute 
must be given. 

I know from long experience that the above prescrip- 
tion may be given for an indefinite length of time (years, 
if necessary) without losing its great therapeutic value or 
producing disgust for it on the part of the patient. I 
have yet to find a patient over ten years of age who 
would not continue the taking of this medicine as long as 
I desired. After the first week or ten days patients grow 
accustomed to it, and then even the most sensitive no 
longer object to its use. This medicine, moreover, is 
not contra-indicated by any condition of the stomach. It 
is in fact the most valuable formula I have found for the 
stomach neuroses, and is also of value in the treatment 
of chronic gastric catarrh and chronic ulcer of the 
stomach. The condition of the stomach need not deter 
us, therefore, from prescribing this formula. On the 
other hand, " a bad stomach " and intestinal indigestion 
are further indications for its extended use. 

I wish especially to insist that the above formula will 
give better results than the separate use of the various 
medicines which it contains. The great value of the for- 
mula, however, depends upon the fact that it combines 
palatability and simplicity with efficacy of medication; 
and these advantages enable one to treat an essentially 
chronic condition by giving a single dose of medicine in a 
day. 

The siphon formula is put up by Merrill & Co., in the 



2IO NEUROTIC DISORDERS OF CHILDHOOD 

form of granular effervescent salts, under the trade name 
" Akaralgia." These granular salts may be used by- 
patients traveling or otherwise so situated that the 
siphons cannot be had. 

It is my habit in the treatment of this condition to con- 
tinue the above siphon medicine through the winter 
months only, discontinuing its use about April or May. 
Patients under this treatment often go through the winter 
months without a single attack of migraine. On discon- 
tinuing the medicine, however, in April or May, when the 
previous treatment and the climatic conditions make it no 
longer necessary, I usually advise my patients to report 
to me again about the first of the following January, or 
earlier if there is any return of the migrainous symptoms. 
At this time they are again placed upon the siphon medi- 
cine and advised to continue it until the following spring. 
By this plan of giving the above formula for three or four 
months in the year I have succeeded in controlling mi- 
grainous symptoms in a large number of my patients. 

In studying the ingredients of this formula one finds 
the medicines that have been used for many years in the 
treatment of this condition. Magnesium sulphate is 
necessary to overcome the constipation which is present 
in nearly all of the cases, and by its action we unload the 
portal circulation and eliminate the poisons through the 
intestinal canal. Sodium sulphate acts very much in the 
same manner, plus its cholagogue action. Lithium ben- 
zoate acts as an intestinal antiseptic and as an eliminator 
through the kidneys. The small amount of nux vomica 
which the formula contains is added largely to cover its 
soapy taste and thereby make it more palatable. Sodium 



MIGRAINE 211 

salicylate (wintergreen) is the remedy par excellence of 
the prescription. This remedy acts as an intestinal anti- 
septic, increases the functional activity of the liver, and 
diminishes the tendency to acid intoxications which is 
present in this disease. 

There are two other siphon formulae which I occasion- 
ally use in the treatment of migraine. They are as fol- 
lows: 

SIPHON B 

* A 

Sodii sulphatis (granulated) . 
Sodii phosphatis (granulated) 
Sodii salicylatis (wintergreen) 
Tincturae nucis vomicae 
Aquas destil. to make 



2 drams 
I dram 

10 grains 

3 minims 

4 ounces 



M. S. — Take each morning. Dose for an adult. 
SIPHON A 

Potass, bicarbonatis . . 20 grains 

Rochelle salts 1 dram 

Sodii salicylatis (wintergreen) .... 5 grains 

Tincturae gentian comp £ ounce 

Aquae destil. to make 4 ounces 

M. S. — Take each morning. Dose for an adult. 

Siphons B and A may be used in those cases in which 
Siphon C is too laxative in its action. Siphon A is es- 
pecially valuable in those cases of migraine suffering in 
the interval from acid urine, irritable bladder, or muscular 
rheumatism without constipation. The average adult 
dose for each of the siphon formulae — A, B, and C — is 
four ounces, but the dose must be carefully varied to suit 
the age of the patient and the degree of the constipation 
to be relieved. Even when no constipation exists, from 
one to three ounces of one of these formula? is to be given 



212 NEUROTIC DISORDERS OF CHILDHOOD 

as a necessary part of the treatment. Care, however, 
must be exercised to prevent excessive cathartic action 
and consequent intestinal irritation. 

In children under ten years of age instead of the 
siphon formulae I commonly employ some preparation of 
phosphate of soda. This may be given in milk or car- 
bonated water, and where the constipation is obstinate 
Rochelle salts or some preparation of senna in palatable 
solution should be used. When constipation is not 
present I prescribe a solution of sodium benzoate and 
sodium salicylate (wintergreen) in palatable solution. 
A valuable prescription is as follows : 

Sodii benzoatis l£ drams 

Sodii salicylates (wintergreen) .... 30 grains 

Essence pepsin ... .., . . i£ ounces 

Aquae menth. pip. ........ ii ounces 

M. S. — Teaspoonful three times a day for a child six 
years of age. 

In beginning the treatment of every case of migraine, 
whatever the age of the patient may be, and whether or 
not the siphon medication is used, I always prescribe one 
or more of the three following drugs : sodium benzoate, 
sodium salicylate (wintergreen), and cannabis indica, and 
I further advise the drinking of water between meals. 
Sodium benzoate and sodium salicylate (wintergreen) for 
older children and adults is made more palatable by tak- 
ing them in carbonated water. Sodium salicylate (win- 
tergreen) may be given to young children in powders, 
combined with milk sugar; or salol may be used instead 
of the salicylate of soda; it has no advantages, however, 
and is probably not so efficacious. 



I 



MIGRAINE 413 

The proprietary preparation known as colchi-sal may 
be given in place of the sodium salicylate (wintergreen) 
to older children and adults, one capsule after meals. I 
have found it a most valuable aid in the treatment of 
long-standing cases associated with other gouty symp- 
toms. 

Cannabis indica, in one-quarter grain doses two or 
three times a day, is of very great value in controlling the 
paroxysms of migraine in the adult, and may be used for 
three or four weeks, until the patient is well under the 
siphon treatment. I not infrequently combine the 
cannabis indica in a capsule with sodium salicylate (win- 
tergreen) or salol in the treatment of these cases. 

With these drugs to aid the siphon medicine, the 
paroxysms of migraine may be controlled almost from the 
beginning of the treatment. After the patient, however, 
has been under treatment for from three to six weeks, all 
medication other than the siphon medicine may be dis- 
continued. 

In some of the cases, however, it is necessary to give an 
intestinal antiseptic throughout the treatment of the case, 
and for this purpose I commonly use a one-grain salol- 
coated pill of potassium permanganate, taken after 
meals. This pill, which I devised many years ago and 
have used continuously ever since, has proven very effi- 
cacious in my hands. Dr. M. Allen Starr has modified 
this pill under the following formula : 

Sodii sulphocarbal 5 grains 

Kal. permangan. ............ 1 grain 

Betanaphthol I " 

M. S. — One after meals and at night. 



2 14 NEUROTIC DISORDERS OF CHILDHOOD 

This pill is coated with shellac, and is of value in those 
cases requiring an intestinal antiseptic. 

In 1895 * I published a paper upon this same subject, 
in which I recommended the use of the following for- 
mula: 

Sodii salicylates (wintergreen) ... ., ... ., 2 drams 

Sodii phosphatis (dry) 4 " 

Sodii sulphatis (dry) 10 " 

M. S. — A teaspoonful, more or less, to be taken in a glass 
of seltzer water each morning. 

These salts I still prescribe for patients traveling or 
otherwise so situated as to make it impossible for them 
to get the siphon medicine. 

There is one other drug that has long held a deservedly 
high reputation in the treatment of migraine, and that is 
mercury, either in the form of calomel, blue mass, or the 
gray powder. Either calomel or blue mass is a good 
drug to begin the treatment of a case of migraine, and 
even after the patient has been placed upon the siphon 
medicine it may occasionally be beneficial to supplement 
this treatment with a few doses of calomel or a dose of 
blue mass. 

The gray powder of mercury, combined with bicar- 
bonate of soda, I have used with great advantage in the 
treatment of migrainous conditions in children 2 too 
young to take the siphon treatment. In such patients 

1 Medical News, September 7, 1895. 

2 In 1897 I published in the Archives of Pediatrics a series of 
papers on the treatment of this condition in infants and children. 



MIGRAINE 2 I 5 

a laxative formula such as the following may be sub- 
stituted for the siphon medicine: 

S . - 

Sodii sulphatis .... ... ., . " . . 2.\ drams 

Magnesium sulphatis 5 

Lithii benzoatis 2 " 

Aquas destil. to make 3 ounces 

Elixir tarax 3 

M. S. — Tablespoonful before breakfast for a child of 
eight years. 

In the treatment of migrainous cases I have occasion- 
ally noticed that after a prolonged use of the siphon 
treatment patients become slightly nauseated, the tongue 
becomes furred, and there is a dull headache with loss of 
appetite. In this condition dilute nitro-muriatic acid 
acts almost as a specific, but during the time that the acid 
is given compound licorice powder or cascara sagrada 
may be substituted for the siphon medicine. After a 
week of such treatment the siphon medicine may be re- 
sumed. 

Dietetic and Hygienic Treatment. — All that has been 
said in the way of medicinal treatment will be of little 
avail unless it goes hand in hand with proper dietetic and 
hygienic treatment. The most important bit of dietetic 
advice that can be given to a migrainous patient is that he 
should not eat too much. Most of these patients are in 
the habit of eating more than is necessary. It is impor- 
tant, therefore, that any tendency in this direction should 
be restrained. There are also certain articles of diet 
which should be partaken of sparingly or not at all — 



2l6 NEUROTIC DISORDERS OF CHILDHOOD 

coffee, alcohol, red meats, and sweets should for a time, 
at least, be almost if not quite eliminated from the diet 

Patients may be allowed milk, eggs, fish, oysters, the 
white meat of poultry, cereals, fruits, and well-prepared 
vegetables, provided a feeble digestion or some idiosyn- 
crasy on the part of the individual does not exclude one 
or more of the above articles from his diet list. The 
diet to be prescribed in any individual case will of course 
depend upon the age of the patient as well as upon his di- 
gestive capacity and the character of life he leads. 

Exercise in the open air is scarcely less important than 
diet in the treatment of migrainous cases. All kinds of 
outdoor athletic sports are to be advised, and among 
these horseback riding is one of the best. The financial 
condition, the age, and the inclination of the individual 
patient will suggest to the physician the character of out- 
door exercise to be recommended. General massage is 
of great value in the early treatment of patients of feeble 
constitution. 

Before closing the subject of the treatment of mi- 
graine, I would call attention to the great value of certain 
hydropathic measures in the treatment of selected cases. 
The Turkish and vapor baths as well as hot alkaline tub 
baths are of benefit, especially in patients of rather stout 
and robust constitutions. These baths are more effi- 
cacious when accompanied by large potations of water 
and followed by general massage. 



CHAPTER XVI 

RECURRENT VOMITING 

Synonyms. — Cyclic vomiting, lithsemic vomiting, 
periodical vomiting, bilious vomiting. In the present 
state of our knowledge it is probably best to retain the 
name " recurrent vomiting,'' originally used by Gee, in 
describing these cases. 

Definition. — Recurrent vomiting is a symptom group 
closely related to migraine. It is auto-toxic in origin, and 
characterized by recurrent attacks of nausea, persistent 
vomiting, and great prostration. 

ETIOLOGY 

i. Predisposing Causes. — Age. — The great majority 
of these cases occur during infancy and childhood. The 
disease may make its appearance as early as the third 
month, but it is more common between the third and 
tenth year. The tendency is to spontaneous recovery, 
but the attacks may continue into adult life or they may 
be transformed into migraine. 

Sex has little influence. A small majority of the cases, 
however, occur in girls. 

Season. — It is somewhat more common in winter than 
summer. 

Heredity is the most important predisposing factor. 
A family history of migraine or gout is present in nearly 
every case. A general neurotic inheritance is common, 

217 . 



2l8 NEUROTIC DISORDERS OF CHILDHOOD 

and a family history of hereditary recurrent vomiting 
is sometimes noted. 

Constipation. — Nearly all of these patients are con- 
stipated, and there can be little doubt that this is an 
important factor in their etiology. The constipation, 
with the resulting intestinal toxaemia, no doubt con- 
tributes to the general irritability of the nervous system 
in these cases. 

Habits of Life. — Mental overwork and nerve excite- 
ment, when combined with an indoor life and confine- 
ment in ill-ventilated school-rooms, are important pre- 
disposing factors. 

Station in Life. — Nearly all these cases occur among 
the hereditary rich and refined. The poor and uncultured 
are comparatively exempt. This probably means that 
the hereditary gouty tendency, with the mental over- 
work and nerve excitement which is so common among 
cultivated people, are such important predisposing fac- 
tors that the poor and unrefined, in whom they are rare, 
are not especially predisposed to this disease. 

2. Direct Causes. — Nearly all writers are agreed that 
recurrent vomiting is an auto-intoxication. My own 
belief is that both auto and intestinal toxins may play a 
role in producing this symptom group, but I do not 
believe that it is always produced by the same auto or 
intestinal toxins. I am of the opinion, however, that 
the largest percentage of these cases is produced by 
toxins either closely related in their formation to, or 
identical with, the purin bodies. The close hereditary 
relationship which exists between this condition and gout 
and migraine lends strong evidence in support of this 






RECURRENT VOMITING 2ig 

view, and the urine findings elsewhere noted strengthen 
this opinion. 

The acid intoxications which occur during the attack 
are to be considered rather as effects than causes, and 
belong, therefore, to the symptomatology and pathology, 
rather than to the etiology. 

Liver Incompetency. — A functional incompetency of 
the liver is, I believe, an all-important factor. The liver 
in these cases is probably, by heredity, functionally in- 
competent, and, in addition to this, it is perhaps called 
upon by reason of the constitutional gouty taint to do 
an unusual amount of work in converting ammonia and 
the purin bodies into urea. Under these conditions we 
have periods of temporary functional incompetency on 
the part of the liver, and as a result the auto and intes- 
tinal toxins are poured into the general circulation and 
produce, in some instances, recurrent vomiting, and in 
other instances, migraine. In a few days, when these 
poisons have been eliminated and the liver has resumed 
its function, the acute attack is over. 

3. Exciting Causes. — Mental and physical fatigue, 
mental excitement, nervous strain, fright, anger, and 
disappointment are common exciting causes. Over- 
eating is one of the most potent of the exciting factors, 
and acid fruits, berries, vegetables, and wines may pre- 
cipitate an attack. Intestinal toxaemia and reflex irrita- 
tion from the intestinal canal, the eye, naso-pharynx, and 
genito-urinary organs may also be classed among the 
exciting causes. These exciting factors are at times 
apparently so important, and so definitely related to the 
onset of the attack, that the physician may be inclined 



220 NEUROTIC DISORDERS OF CHILDHOOD 

to overestimate their importance, and thus misinterpret 
the true nature of the disease. It should always be kept 
in mind that in these patients there is a tendency to the 
recurrence of auto-intoxications, which are the true 
causes of the attack, and the particular reflex factor 
which happens to touch off the paroxysm is not to be 
considered as the all-important causative factor. 

SYMPTOMS 

Prodromes are almost always present from a few hours 
to a few days before an attack. Among the more con- 
stant warning symptoms are flushings of the cheek, 
coryza, general restlessness, nervous irritability, sleepless- 
ness, sallowness of complexion, dark rings under the 
eyes, general malaise, constipation, coated tongue, a 
peculiar odor to the breath, and loss of appetite. Not 
all of these prodromes are present in any one case, but 
in the great majority of cases the mother or nurse, having 
observed the onset of other attacks, will recognize, by 
certain of these warning symptoms, that a paroxysm of 
recurrent vomiting is imminent. Recently I have espe- 
cially been interested in vasomotor coryza as an almost 
constant warning symptom in a number of cases. 

Vomiting. — Following the prodromes, from six to 
forty-eight hours, vomiting occurs. This is the most 
characteristic and prominent symptom. In the begin- 
ning the vomiting may not be severe, food only being 
rejected; in a few hours, however (six to twenty- four), 
it becomes very severe, and accompanied by more or less 
constant nausea; not only everything that is taken into 
the stomach is rejected, but bile and much mucus some- 



RECURRENT VOMITING 221 

times tinged with blood is expelled. In severe cases the 
vomiting is accompanied by violent retching, and is oft- 
repeated without apparent cause. The severe vomiting 
may continue from one to six days, and then, as a rule, 
disappears as suddenly as it came, and with its disap- 
pearance convalescence is established. Following an 
attack the stomach, as a rule, resumes its functions, and 
within five or six days the patient is taking his ordinary 
food without the slightest discomfort on the part of 
the digestive organs. From this time on the patient 
rapidly regains his health and strength, and may mani- 
fest no gastric symptoms whatever until the next attack, 
which may recur within a month ; but as a rule the inter- 
val is from two to six months. Subsequent attacks are 
very similar in their symptomatology to the initial attack. 
They may vary, however, very greatly in severity and 
duration. The first attack is, as a rule, diagnosed as a 
case of ordinary toxic gastritis, due to ptomain or other 
poisoning, and every effort is made to discover in the 
food or vomited matter the cause of the attack. When 
the second and third attacks follow, in spite of careful 
feeding and without apparent cause, the physician recog- 
nizes their constitutional origin and makes the diagnosis 
of recurrent vomiting. 

While it is the rule that patients who suffer from recur- 
rent vomiting may have in the interval no stomach or 
intestinal disturbance, yet this is a rule that has many 
exceptions, especially in patients under five years of age. 
Many of these are prone to have gastro-enteric disturb- 
ances at all times from very slight causes, and many 
of them during the first three years of life have more 



222 NEUROTIC DISORDERS OF CHILDHOOD 

or less trouble digesting cow's milk. In these cases 
frequent attacks of gastric indigestion with mild intesti- 
nal fermentations will now and then be broken in upon 
by an attack of recurrent vomiting, and following this 
acute attack the patient again returns to his usual condi- 
tion of health. These chronic cases are, I believe, 
analogous to those of chronic migraine described else- 
where, and while they are vastly more common in young 
infants, they may occur at any age. 

Character of the Vomited Matter. — Snow says : " It is 
to me remarkable, in an illness whose main symptom is 
vomiting, that so few accurate analyses have been made 
of the vomited matter. Testing the ejecta would seem 
to me to be the clew to correct diagnosis and treatment. 
However, Holt reports the usual findings, as of a fluid, 
containing mucus and free HC1. In four of my personal 
cases the fluid vomited was apparently pure gastric juice, 
containing an excess of free HC1 and mucus, and in the 
fifth case the hyperacidity was due to combined chlorides. 
It is, therefore, probable that some cases of recurrent 
vomiting are the result of an intermittent form of hyper- 
secretion of highly acid gastric juice." 

It appears, however, to me that the hyperchlorhydria 
which Snow describes in these cases, while it may aggra- 
vate the vomiting in some of the cases, is but one of the 
symptoms of this neurosis, and not its prime etiological 
factor. 

Constipation which precedes the attack becomes, as a 
rule, very obstinate during the attack, and, owing to the 
irritable condition of the stomach, which forbids medi- 
cation, and the arrest of peristalsis, which accompanies 



RECURRENT VOMITING 22 3 

the attack, it is at times almost impossible to relieve it. 
When the constipation is relieved by cathartics, or by 
the cessation of the attack, the discharges are putrid. A 
few of the cases reported have had loose putrid move- 
ments throughout the attack, and this, while unusual, is 
more likely to occur in very young patients. 

Thirst. — While there is absolutely no desire for food 
in most cases, thirst is a striking symptom. The little 
patients are frequently asking for water, even when it 
is immediately rejected. When the attacks are prolonged, 
and when no food or water has been retained for days, 
the thirst is excessive, and there is usually a parched, dry 
tongue. 

Emaciation is great in the aggravated, long-continued 
cases. There are few diseases that produce more emacia- 
tion in a shorter period of time. As little or no fluid 
is retained in many of these cases, the tissues are drained 
of water, and as a result the general emaciation is very 
rapid. The abdomen is boat-like or flattened, the eyes 
are sunken, and this, with the anxious expression of 
countenance, gives the impression of great danger to 
life. 

The prostration in these cases keeps pace with the 
emaciation. In all cases it is marked, and in some cases 
so extreme as to demand the most powerful stimulants 
to tide the patient over the attack. 

Fever is present in nearly every case under ten years 
of age. From this time on fever is less common, until 
in adult life it is, as a rule, absent. The fever occurs 
early in the disease, often among the prodromes. It 
may continue for two or three days, varying in height 



224 NEUROTIC DISORDERS OF CHILDHOOD 

from ioi° to 105 F. As a rule, after the second or 
third day the temperature commences to subside, and in 
the latter stages may be subnormal. At times the fever 
subsides very early in the attack, with the onset of severe 
vomiting. 

The pulse is irregular, as a rule, and usually rapid. 

The tongue in the beginning may be coated, but in 
the latter stages of severe attacks is dry. The peculiar 
acetone odor of the breath becomes more marked as the 
attack progresses. A few of these cases complain of 
sore throat during the attack, and in these cases the 
pharynx and tonsils may be irritated. 

Respiration may be sighing, or rapid and panting, out 
of proportion to the pulse and temperature. The respira- 
tory phenomena in this disease are probably due to the 
direct irritation of these centers by toxins. 

Narcotism, which marks the characteristic close of 
the migrainous attack, is, from my own experience, not 
uncommon in this condition. Almost nothing is said 
concerning this symptom in the reported cases. I am, 
however, of the opinion that in nearly all of the severe 
cases there is, in the latter stages, a tendency to somno- 
lence, and that a prolonged sleep, not infrequently, is 
followed by the first indications of improvement. In 
the earlier cases of this disease which I reported I failed 
to note this symptom. 

Gastric pain is not present during these attacks in chil- 
dren. I believe, however, that in the adult gastric pain 
of great severity may occur, associated with a severe 
recurrent vomiting. In some of these cases, at any rate, 
we have a symptom group exactly similar to that of the 



RECURRENT VOMITING 22 5 

child, plus the gastric pain, and these painful attacks 
may occasionally alternate with painless attacks of recur- 
rent vomiting or with migraine. These are, perhaps, 
the cases of periodical vomiting described by Leyden. 

Nervous Symptoms. — While patients suffering from 
recurrent vomiting may be perfectly free from gas- 
troenteric disturbances during the interval, they are, one 
and all, nervous, presenting varying degrees of general 
nervous excitability and restlessness. Snow described 
a case in which convulsions occurred at the onset of 
nearly every attack, and I have seen two such cases. Many 
of these children are precocious, and this precocity, like 
the precocity of migrainous children, may, if properly 
guarded and restrained, continue throughout adult life. 
The precocity of the gouty child, whether the child be 
subject to any of the gouty explosive neuroses or not, 
is to be distinguished from the precocity which occurs 
in tuberculous children. Children of tuberculous type 
are usually undersized and whimsical, and their pre- 
cocity, which is coupled with physical inferiority, is fitful 
and sadly lacking in symmetry. The mental precocity 
of the gouty child, however, does not necessarily mean 
physical degeneracy, and it may, if properly treated, be 
sustained and continued throughout the life of the 
individual. 

Urine. — The urine, in a case described by Holt, re- 
sembled that passed during an attack of migraine. It 
becomes more scanty as the attack progresses. It is 
very concentrated and strongly acid in reaction. This 
acidity causes a rather heavy deposit of uric acid and 
urates, although the percentage of uric acid is not in- 



226 NEUROTIC DISORDERS OF CHILDHOOD 

creased. The xanthin bodies, however, are in great 
excess. Albumin may be present in small quantities dur- 
ing the attack, although this is rather uncommon. Ace- 
tone and indican are present in perhaps all of the severe 
cases. Many observers have found acetone in the urine 
of these cases, and Marfan published a series of cases 
which he described as " vomiting with acetonemia," and 
suggested that acid intoxications may be a phase of this 
disorder. More recently Edsall found not only acetone, 
but diacetic acid and oxybutyric acid in the urine of a 
number of these cases. 

DIAGNOSIS 

The diagnosis of recurrent vomiting is easily made if 
the above symptom group is kept in mind. No disease 
presents exactly the same picture. In the atypical cases, 
however, and especially in the first attack, there may be 
considerable difficulty. But after the second and third 
attacks the nature of the disease is made plain. In the 
first attack the condition is most commonly mistaken for 
a ptomain or other toxic gastritis. The intestinal symp- 
toms, however, which develop in gastritis, and the cessa- 
tion of the vomiting under starvation and proper treat- 
ment, should enable one to make the diagnosis. 

Intestinal obstruction, as Griffith suggests, may proba- 
bly offer the greatest difficulty in differential diagnosis, 
but the absence of pain and bloody mucus in the stools 
and of any tumor, with the presence of the characteristic 
symptom group, above described, should be sufficient to 
clear the diagnosis. 

The presence of acetone in the urine with the other 



RECURRENT VOMITING 227 

urine findings, above noted, would assist in making the 
diagnosis. 

PROGNOSIS 

The prognosis, so far as recovery from the attack 
is concerned, is good. The vast majority of these 
cases recover. It should be kept in mind, however, 
since a number of fatal cases have been reported, that 
there is a possibility of a fatal ending. The prognosis, 
so far as the prevention of these attacks, is also good. 
Most of these cases can be cured, and all of them can be 
greatly benefited. Under proper treatment the attacks 
cease, and the child's general neurotic condition greatly 
improves. This improvement goes on, and as the child 
grows older its nervous system becomes more stable and 
the tendency to these recurring attacks is overcome. In 
the untreated cases these attacks may be transformed into 
migraine or epilepsy. 

PATHOLOGY AND NATURE OF THE DISEASE 

Little is known of the pathology of this disease. An 
autopsy reported by Griffith showed necrotic changes in 
the mucous membrane of the stomach and intestine, and 
slight parenchymatous alterations in the pancreas, spleen 
and kidneys, and fatty infiltration of the liver. Our pres- 
ent knowledge of this condition justifies us in the belief 
that the disease is an auto-intoxication produced by 
toxins closely related or identical with the purin bodies, 
and that a secondary acid intoxication occurs, which may 
contribute to the symptom group in the later stages of 
the attack. The auto-toxins in this condition select the 
vomiting center in the medulla as their point of attack. 



22 8 NEUROTIC DISORDERS OF CHILDHOOD 

The close family relationship which exists between mi- 
graine and recurrent vomiting has been previously noted, 
and I wish here, especially, to note the fact that I have 
records of four of my own cases where typical attacks of 
recurrent vomiting were changed into typical attacks 
of migraine as the children grew older. 

In the present state of our knowledge, acetonuria 
means an excess of diacetic and oxybutyric acid in the 
urine ; we may infer, therefore, that in all of the reported 
cases in which acetone occurred in the urine these acids 
were also present. Von Noorden says : " Owing to the 
fact that this acid (oxybutyric) is so closely related 
chemically to acetone and diacetic acid, one is justified 
in suspecting its presence in the urine whenever these two 
bodies are excreted in considerable quantities. As a 
matter of fact, one always succeeds in finding the acid 
under these circumstances.'' In the light of these obser- 
vations published reports warrant the inference that ace- 
tonuria, with at least a mild degree of acid intoxication, 
occurs after the onset of the attack in perhaps all of the 
severe cases. The acid intoxication, however, is in this 
disease, as it is in many others, a purely secondary patho- 
logical process. Von Noorden believes that all acid 
intoxications produced by the presence in the tissues of 
acetone, diacetic, and oxybutyric acids are due largely, 
if not wholly, to an insufficient intake of carbohydrate 
food, or to some fault in the carbohydrate metabolism. 
A study of acid intoxications reveals the fact that this 
form of secondary auto-intoxication very commonly oc- 
curs in diseases which produce profound nutritional dis- 
turbances. In recurrent vomiting, therefore, we have 



RECURRENT VOMITING 229 

ail the conditions necessary to produce acid intoxications ; 
first, an insufficient intake of carbohydrate food; second, 
profound nutritional disturbances, and third, faulty car- 
bohydrate metabolism produced by the functional inca- 
pacity of the liver. The acid intoxications in this condi- 
tion are, therefore, secondary rather than primary. 
It may further be noted that the characteristic symptom 
group which this disease presents is not that of acid 
intoxication, but in the later stages of this disease, when 
the acid intoxication is more marked, it is possible that 
the respiratory disturbances, the increased pulse rate, 
the lowering of the body temperature, and the tend- 
ency to somnolence may perhaps be partly due to this 
intoxication. 

TREATMENT 

Treatment of Attack. — If seen in the prodromal stage, 
J of a grain of calomel and 5 grains of bicarbonate of 
soda should be given every half-hour until 2 grains of 
calomel are taken. And if the stomach be not too irrita- 
ble, the calomel should be followed in two or three hours 
by a saline laxative, and four or five hours later by ben- 
zoate of soda in from 3 to 8 grain doses every two or 
three hours, dissolved in essence of pepsin and pepper- 
mint water. No food whatever should be given. Water 
may be allowed if the stomach will retain it. 

After the attack is well on, the nausea and vomiting 
preclude not only all food, but all stomach medication. 
The calomel and bicarbonate of soda, however, may be 
tried at any stage of the attack, and if the nausea and 
vomiting are not greatly aggravated by them, they may 



23O NEUROTIC DISORDERS OF CHILDHOOD 

be continued. At intervals throughout the attack water 
may be allowed, even though the stomach rejects it; but 
no food is to be given until the patient is able to retain 
water in small quantities. 

In cases where food and water are not retained by the 
stomach it is advisable to give, at intervals of every eight 
to twelve hours, a high rectal enema of physiological salt 
solution, or bicarbonate of soda solution, a tablespoonful 
to the pint of water. The tissues, as a rule, are so 
starved for water that these solutions are absorbed, and 
the water thus absorbed serves to flush out the various 
excretory organs and in this way promote the excretion 
of auto-toxins. The bicarbonate of soda given by the 
rectum or the mouth serves the purpose of neutraliz- 
ing acids, thus removing or preventing the secondary 
acid intoxications which occur in these cases. Edsall's 
suggestion that very large doses of bicarbonate of soda 
be given by the mouth is a good one in those cases in 
which the soda is retained, but my experience is that the 
cases which need this treatment most are the ones which 
retain nothing on the stomach. In some cases, however, 
the soda is retained when all else is vomited, and even in 
those cases where it is immediately rejected it may perhaps 
do some good by neutralizing the acids in the stomach. 

In the most aggravated cases, where prostration is 
extreme and stimulation strongly indicated, sterile 
physiological salt solution may be injected into the sub- 
cutaneous tissues. In cases of this kind, also, it occasion- 
ally becomes necessary to give morphine hypodermically. 
This remedy acts specifically in the control of the vomit- 
ing, and in the worst cases it is a life-saving measure. 



RECURRENT VOMITING 2$t 

Small doses of from i-io to 1-20 of a grain, depending 
upon the age of the patient, are usually sufficient. 

Hygienic and Climatic Treatment. — It will be found 
that many of these children prefer an indoor life and in- 
tellectual pursuits. For habits of this kind, an outdoor 
life, with moderate exercise in the open air and in a 
suitable climate, should be substituted. Since these 
cases occur very commonly among the well-to-do, it is 
often possible to prescribe an outdoor climate the year 
round. Our Southern States, and especially Southern 
California, are admirable winter climates for these chil- 
dren, while the region of the Great Lakes or the sea-coast 
of our North Atlantic States offer favorable climatic con- 
ditions during the summer. Sea voyages are also beneficial. 

It should be remembered that while the climatic treat- 
ment of many of these cases is important, it does not take 
precedence over the medical, dietetic, and general hygienic 
treatment which may be carried out in any climate ; and 
my experience leads me to believe that these cases do 
better at home during the greater portion of the year, 
provided the home offers favorable opportunities for 
carrying out the general treatment here outlined. But 
even where the treatment is carried out under favorable 
home conditions a change of climate for a few months 
during the year is advisable, and by this change the hot 
months of summer or the cold of winter may be avoided, 
as the climatic conditions at home may dictate. 

These children should, as a rule, be taken out of school, 
and lead as quiet and uneventful lives as possible. Men- 
tal stimulation, nervous excitement, and all forms of 
mental and physical fatigue are to be avoided for a num- 



232 NEUROTIC DISORDERS OF CHILDHOOD 

ber of years, or until the child's physical and nervous 
condition justifies a return to the ordinary routine of 
child life. 

Dietetic Treatment. — The diet should be carefully 
restricted, and selected. In beginning the treatment all 
raw fruits and acid vegetables are to be eliminated from 
the diet. Strawberries, rhubarb, tomatoes, salads, tea, 
coffee, beef juice, beef tea, and alcohol are to be avoided, 
and the child should be allowed to eat but sparingly of 
beef and sweets. The following foods may be recom- 
mended: Milk, cocoa, vegetable soups, cereals, well- 
cooked vegetables, cooked fruits, eggs, fish, chicken, mut- 
ton, and, occasionally, beef. Children suffering from 
recurrent vomiting have, as a rule, in the interval between 
the attacks abnormally large appetites. They are there- 
fore to be carefully guarded against taking an excess of 
food of any kind, and are to be made to cultivate the 
habit of drinking water between meals. 

Medical and other Treatment. — Before beginning the 
medical treatment sources of reflex irritation on the part 
of the eye and elsewhere should be carefully sought for 
and, if possible, removed. Constipation, which is con- 
stantly present in this condition, demands our most 
thoughtful consideration. It must be relieved. This 
can usually be done by palatable solutions of sulphate and 
phosphate of soda. These saline laxatives are advisable 
in the beginning of the treatment. Later, palatable mix- 
tures of rhubarb and cascara sagrada may be used. 
Enemata are not to be relied upon in the treatment of 
this condition. Abdominal massage may sometimes re- 
lieve the constipation, and where it is necessary to resort 



RECURRENT VOMITING 233 

to massage for this purpose, it is advisable to give the 
patient general massage at the same time. 

I am coming more and more to believe that general 
massage, apart from the influence it may have on con- 
stipation, is one of the most valuable remedies we have 
in overcoming the constitutional conditions which pre- 
dispose to recurrent vomiting. This is especially true 
in patients of feeble constitution so situated that an out- 
door life with active exercise cannot be had. In begin- 
ning this treatment the massage may be given every day, 
every second day, or two or three times a week, according 
to the exigencies of the case, and should be continued 
until the child's physical condition is such that he can lead 
a strenuous outdoor life without undue fatigue or other 
untoward results. 

In the medical treatment of this condition, however, 
the wintergreen salicylate of soda and the benzoate of 
soda, put up in palatable solution in a dose to suit the 
age of the child, are our most valuable remedies. The 
following prescriptions will be found to act specifically 
in preventing attacks. 

Sodii salicylates (gaultheria) i dram 

Sodii benzoatis 2 drams 

Pepsin essence 2 ounces 

Aquae menth. pip 2 " 

M. S. — Teaspoonful after meals for a child six years of 
age. 

£ _ __ 

Sodii bicarbonatis . 60 grains 

Hydrarg. cum cretae 20 " 

M. — Ft. capsules No. 20. 

Sig — One capsule three times a day. 



2^4 NEUROTIC DISORDERS OF CHILDHOOD 

In the more severe cases one of these prescriptions 
must be continued, as above directed, for months at a 
time, and after this is to be given once or twice a day 
for an indefinite period. 

In children over six years of age nothing within the 
range of my experience acts so well in the treatment of 
the underlying constitutional condition as Siphon C (see 
"Treatment of Migraine," page 208). Children above 
this age can be induced to take early each morning a dose 
of this siphon sufficient to produce a movement of the 
bowels during the forenoon. This one dose of medi- 
cine each morning will, I believe, with the dietetic and 
hygienic treatment above outlined, protect the child 
against future attacks. It will, however, perhaps be 
safer in the early treatment of the case to give, in connec- 
tion with the siphon medicine, the salicylate of soda pre- 
scription above noted. After a few months of treatment, 
however, all medication other than the siphon formula 
may be discontinued. I have found it necessary occa- 
sionally to interrupt the alkaline treatment and substitute 
such tonics as malt and arsenic. In this event, however, 
it is necessary to give some such laxative as cascara 
sagrada. 

The general treatment here given is largely the same 
as that outlined by me in 1898, in the " American Text- 
Book of Diseases of Children," and many years of experi- 
ence have taught me that under this treatment the prog- 
nosis, even in the most severe cases of recurrent 
vomiting, is good not only as to the prevention of attacks, 
but also as to permanent recovery. 



CHAPTER XVII 

EPILEPSY 

Definition. — The syndrome which, regardless of its 
etiology, we call epilepsy is characterized by habitually 
recurring convulsive seizures, local or general, accom- 
panied by temporary loss of consciousness, and commonly 
terminated by a narcosis which produces a sleep from 
which the patient awakens convalescent from the attack. 

Epilepsy in its early history was spoken of as the 
" falling sickness." This loss of equilibrium was thought 
by the earlier writers to be a necessary symptom. At the 
present time, however, we recognize a large group of 
seizures as epileptic in which this symptom is absent, 
and many of our best medical authorities now assert 
that neither loss of consciousness nor convulsive move- 
ments are necessary to an epileptic seizure. By these 
writers the syndrome of epilepsy has been deprived of one 
after another of its symptoms, until there now remains, as 
a necessary characteristic of the epileptic paroxysm, only 
the habitual recurrence of attacks, not especially defined 
as to their nature. 

Since the pathology of epilepsy is so obscure and since 
the term includes a number of conditions differing widely 
in their pathology, it is manifestly impossible to satis- 
factorily define epilepsy from an etiological or patho- 
logical standpoint. In this dilemma the term epilepsy 
has come to mean a well-defined symptom group, which 

255 



236 NEUROTIC DISORDERS OF CHILDHOOD 

has striking characteristics, notwithstanding its diversi- 
fied etiology and pathology. It seems, therefore, that 
until a definite etiological or pathological basis of 
classification can be decided upon by which we may 
determine what is and what is not epilepsy, it is most 
important that a definite syndrome should be recognized 
as epilepsy; otherwise all is confusion. The character- 
istics of the syndrome of epilepsy as recognized in this 
chapter are not only habitually recurring attacks, but 
loss of consciousness and convulsive muscular action, be 
they ever so slight. 

The great variation in severity of these symptoms, 
with the addition of a large number of other symptoms, 
gives great variation to the clinical picture presented by 
individual attacks of epilepsy, and justifies their sepa- 
ration into rather well-defined clinical groups. 

PATHOLOGY 

If the literature of epilepsy is agreed upon any one 
fact pertaining to its pathology, it is that the most im- 
portant factor in its production is an irritation of the 
motor neurons of the cerebral cortex. The irritation 
which causes the violent and rapid discharge of nerve 
force may be either chemical, mechanical, or reflex. 

Epilepsy from a pathological standpoint may be di- 
vided into three distinct types, Developmental, Organic, 
and Toxic. 

DEVELOPMENTAL EPILEPSY 

Developmental Epilepsy, the synonyms for which are 
idiopathic, hereditary, and reflex epilepsies, has as its 



EPILEPSY 21J 

underlying pathological condition a lack of development 
of the higher inhibitory centers which control spinal 
convulsive movements. This lack of inhibition makes 
it possible for slight reflex causes to precipitate a dis- 
charge of nerve force into the spinal motor cells, produc- 
ing epileptic convulsions. While the reflex factor in 
this form of epilepsy may be necessary, it is not the most 
important factor, since reflexes would be impotent if it 
were not for the lack of inhibition and the irritable nerve 
centers which make these factors effective. The essen- 
tial factor, therefore, is a developmental one, the nerve 
centers of the cortex having failed to acquire the neces- 
sary inhibitory control over lower centers. 

This form of epilepsy is also spoken of as " hered- 
itary," since the hereditary factor is here more marked 
than in any other. In more than one-third of these 
cases there is a family history of eclampsia, epilepsy, or 
insanity, and not infrequently a number of children in 
the same family are affected. The hereditary factor 
is here direct, since all of these disorders are characterized 
by a lack of inhibition. Feeble inhibition is, therefore, in 
a large percentage of these cases directly inherited. A 
family history of other hereditary neuroses is also com- 
mon. This is the type of epilepsy that is believed by 
some writers to be occasionally produced by infantile 
eclampsia. The eclampsia which occurs in the early 
history of these cases is not the cause of the epilepsy, 
but both are made possible by the hereditary weaknesses 
of the nervous system above noted. 

Chronic malnutrition is a very important factor in 
producing this form of epilepsy; it acts by still further 



238 NEUROTIC DISORDERS OF CHILDHOOD 

weakening the hereditary defects above noted. (In 
Chapter II, I have noted the influence of malnutrition in 
interfering with the development of inhibition in the 
rapidly developing nervous system of the young child.) 
One can readily see, therefore, that such diseases as 
rachitis, chronic gastro-intestinal disorders, tuberculosis, 
rheumatism, heart disease, the acute infections, and all 
the diseases of childhood which produce chronic anaemia, 
and consequently chronic malnutrition of the nervous 
system, may assist in the development of this type of 
epilepsy in children who have inherited feeble inhibition. 
This group of epilepsies is probably the largest of all, 
but it is not so large as was formerly supposed, since 
many of the cases previously classed as idiopathic or de- 
velopmental are now known to be due to organic dis- 
eases of the nervous system. 

ORGANIC EPILEPSY 

Synonyms. — Symptomatic, mechanical, focal, and 
Jacksonian epilepsy. 

Organic epilepsy has as its essential pathological con- 
dition some organic disease of the nervous system, such 
as porencephalus ; microcephalus ; cysts formed by a soft- 
ening of the brain substance secondary to obstruction of 
the middle cerebral artery or to thrombosis; tumors of 
the brain and cord due to secondary syphilis or other 
causes; traumatism producing fracture of the skull or 
cerebral hemorrhage; lastly, and most important of all, 
cortical hemorrhages occuring as one of the accidents 
of birth, or resulting from severe convulsions, or injury 
to the head in very early infancy. 






EPILEPSY 239 

In the injury to the brain which results from fracture 
of the skull, hemorrhage, or tumor, mechanical irritation 
produces a circumscribed menigo-encephalitis, resulting 
in more or less degeneration of the cells of the cerebral 
cortex and sclerosis of the neuroglia tissue. These 
secondary changes explain the continuation of the epi- 
leptic paroxysms after the original excitants have been 
removed. It has long been known that these injuries 
to the brain are responsible for a large number of epi- 
lepsies; but a new interest has been added to this subject 
by the admirable clinical studies of B. Sachs, who has 
demonstrated that many obscure epilepsies developed in 
late childhood are focal epilepsies having their origin 
in cortical hemorrhages which occurred in infancy. In 
many of these cases the epilepsy develops long after the 
paralysis and spastic palsy has disappeared, so that they 
are commonly classed as developmental, or idipathic 
epilepsy. In these cases a careful inquiry into the pre- 
vious history of the child may discover a paralysis in 
early infancy, and a careful examination of the patient 
may show an exaggeration of deep reflexes, or an in- 
equality in the strength of the muscles on the two sides. 
The dynamometer, for example, may show that the mus- 
cles of the hand are weaker on the side of the body which 
presents the exaggerated reflexes. By these signs and 
symptoms, as well as from the early personal history of 
the patient, one is often able to make a diagnosis of or- 
ganic epilepsy in cases that would otherwise be classed 
as developmental. Epilepsy due to tumors of the brain 
and cord and to hemorrhagic lesions in the region of 
the basal ganglia, such as arterial obstruction and 



24O NEUROTIC DISORDERS OF CHILDHOOD 

thromboses, apparently prove that cortical irritation is 
not absolutely necessary to the production of epilepsy. 
These hemorrhagic lesions may follow heart disease, 
rheumatism, scarlet fever, pneumonia, and other acute 
infections, so that in rare cases these diseases may be 
classed as etiological factors of this form of epilepsy. 

Heredity plays an unimportant role in the production 
of organic epilepsy. 

TOXIC EPILEPSY 

Synonyms. — Migrainous, lithaemic, and leucomain 
epilepsy. 

There is a type of epilepsy which may be classed as 
toxic, the essential factors in the production of which 
are auto-toxins. In this type of epilepsy the auto- 
toxins act upon the convulsive centers at the base of 
the brain, producing convulsions in the same manner that 
toxins produce the eclampsia of infancy. The epileptic 
convulsions produced in this manner are in every way 
similar to toxic infantile convulsions. All that is neces- 
sary to convert an ordinary toxic eclampsia into an epi- 
lepsy is to have the intoxications and consequent con- 
vulsive seizures recur often enough to establish the 
epileptic habit. When this habit has been established 
it is possible that epileptic convulsions may occur, not 
directly caused by anto-toxins; yet this type of epilepsy 
is essentially auto-toxic in origin, and for the most part 
the subsequent convulsive seizures are, as I believe, pro- 
duced by recurring attacks of auto-intoxication in the 
same manner that migraine and recurrent vomiting are 
produced. 



EPILEPSY 24I 

A large group of these toxic epilepsies, is, I believe, 
produced by auto-intoxins, either identical with or closely 
related in their formation to the purin bodies. This is 
the form of epilepsy which is so closely related to mi- 
graine, and which furnishes the connecting link between 
these two syndromes. 

Toxic epilepsy is not in any way related to the organic 
form. It may, however, be related to developmental 
epilepsy in that certain individuals may inherit both fee- 
ble inhibitory control of motor nerve centers and a pre- 
disposition to migraine. In such cases as these the 
inefficiency of the inhibitory centers not being sufficient 
to produce epilepsy, the auto-intoxication which would 
otherwise manifest itself in an attack of migraine now 
becomes an attack of epilepsy. The auto-intoxication 
thus becomes the all-important factor in developing the 
epileptic habit. As time goes on and recurring attacks 
of auto-intoxication produce recurring attacks of epi- 
lepsy, the inhibitory weakness of the cortical centers may 
become so exaggerated as to convert the case into a mix- 
ture of the developmental and toxic types of epilepsy, so 
that slight epileptic paroxysms may at times be produced 
by trivial reflex causes, and at other times severe par- 
oxysms may be produced by the recurring auto-intoxica- 
tion. 

In the development of nearly all of these cases there 
is a history of attacks of migraine extending over a num- 
ber of years before the epilepsy appeared. The par- 
oxysms of epilepsy may then be substituted for those of 
migraine, and thereafter the case may be one of epilepsy, 
or of epilepsy alternating with migraine. In all of 



242 NEUROTIC DISORDERS OF CHILDHOOD 

these cases there is a family history of either gout or 
migraine. 

In one of my cases in which there was no family his- 
tory of epilepsy, but a very strong family history of 
gout, migraine, and recurrent vomiting, the patient her- 
self suffered from recurrent vomiting until she was twelve 
years of age; the attacks were then transformed into 
migraine, from which she suffered for three years; at 
the age of fourteen epilepsy began to alternate with mi- 
graine, and a few years later, the epileptic habit being es- 
tablished, all of the attacks became true epilepsy. The 
epileptic attacks in this case were frequently preceded 
and followed by a severe unilateral headache, giving the 
symptom complex of both migraine and epilepsy. 

The sequence in this case of recurrent vomiting, mi- 
graine, and epilepsy was unmistakable, and there seems 
little room for doubt that all were produced by the same 
or a very similar auto-intoxication. I have in previous 
chapters noted the kinship which exists between recur- 
rent vomiting and migraine; the relationship which ex- 
ists between migraine and epilepsy is a matter of medical 
history. Concerning this relationship, Landon Carter 
Gray says : " Some eleven years ago I called attention 
to the association of epilepsy with migraine, not knowing 
until some time later that Tisset, Parry, and Liveing had 
previously observed the same association. In these cases 
epilepsy alternates with migraine, the migraine disap- 
pearing when the epilepsy appears, and the epilepsy 
returning when the migraine disappears. By this I do 
not mean to say that all cases of migraine are subject to 
epilepsy, but I do mean to say that there is a very close 



EPILEPSY 243 

relationship between migraine and epilepsy, and in some 
cases the relation is so close as to permit of this alterna- 
tion; indeed, almost all cases of migraine will be found 
at some period of their lives to have had a loss of con- 
sciousness with or without convulsive movements, 
although generally this fact is strenuously denied." 

All recent writers upon this subject speak of the close 
relationship of migraine and epilepsy, so that I think 
one is justified in asserting that these two syndromes are 
not infrequently twin inheritances from the same gouty 
ancestors. I wish to insist, however, that migraine 
bears this close etiological relationship only to toxic epi- 
lepsy, that it is not in any way related to organic epilepsy, 
and that it is not related, but may be associated with, de- 
velopmental epilepsy in the manner above described. 

The urine passed by patients suffering from migrain- 
ous epilepsy is similar to that passed by patients suffer- 
ing from true migraine. It is usually concentrated, highly 
colored, strongly acid in reaction, and has a heavy de- 
posit of urates. The uric acid is not increased in quan- 
tity, but the xanthin bodies are. 

Intestinal Toxcemia. — Herter and Smith in an admira- 
ble research have called attention to the influence of in- 
testinal toxins in producing epilepsy. Their observa- 
tions show that intestinal putrefaction is very common in 
epileptics. A large percentage of these cases, as shown 
by the presence of ethereal sulphates in their urine, were 
suffering from some degree of intestinal toxaemia. In 
these cases, however, the intestinal toxaemia was a 
constant condition and not especially associated with the 
seizures. The inference therefore is that the intestinal 



244 



NEUROTIC DISORDERS OF CHILDHOOD 



intoxication in these cases may have aggravated the 
general nervous irritability of these patients, and in that 
way aggravated or increased the number of their at- 
tacks. It does not appear, however, that the intestinal 
intoxication was the essential cause of the epilepsy in 
these cases, and such in fact is not claimed by Herter 
and Smith. It is important, however, to keep in mind 
the fact that constipation and resulting intestinal fer- 
mentation, which are so common in the toxic and devel- 
opmental types of epilepsy, may be contributing factors, 
and therefore justify careful therapeutic attention. 

GENERAL ETIOLOGY 

Age is an important etiological factor in the various 
types of epilepsy. The organic type of epilepsy com- 
monly begins before the tenth year; the developmental 
between the tenth and the twentieth year, and the toxic 
after the twentieth year. Cases of epilepsy, however, 
belonging to any of the above types may occur at any 
of these periods. Gowers analyzed 1450 cases of epi- 
lepsy, and found that they occurred regardless of their 
types as follows: 



Under 


10 years 


. 




From 


10 to 


19 years 




1 


20 " 


29 


a 






i 


3o" 


39 


( 






H 


40 " 


49 


( 






it 


50" 


59 


( 






it 


60 " 


69 


t 






U 


7o" 


79 


it 





422 cases 

665 

224 

87 
3i 
16 

4 

1 case 



EPILEPSY 24$ 

Sex. — Females are rather more liable to be affected 
than males. This is largely due to the influence of 
menstruation. 

Exciting Causes. — I do not believe that reflex causes 
are ever wholly responsible for the development of a case 
of epilepsy. I have, in the chapter on " Reflex Irritation," 
called attention to the fact that the constant nagging of 
reflexes may, if continued for a sufficient length of time, 
produce marked changes in the cells of the spinal cord; 
changes from which these cells require a long period of 
rest to recover. Spinal cord cells, subjected to such in- 
fluences, become abnormally irritable and excitable. They 
discharge their nerve force fitfully, and under slight reflex 
provocation. If the chronic reflex irritation, however, 
be removed, and the cells be allowed a sufficient period 
of rest, they return to their normal condition, both as to 
structure and function. In the light of these physiolog- 
ical facts one may suppose that the various ganglia of the 
brain, or the motor cells of the cortex, may in like manner 
be so structurally and physiologically changed by strong 
chronic reflex irritation that they become irritable and 
discharge their nerve force under slight provocation. If 
this be true, one can understand how long-continued 
chronic reflex irritation, from eye-strain and from dis- 
eases of the throat and nose, may be very strong exciting 
causes in the development of epilepsy, and one can under- 
stand how these causes, when combined with an heredi- 
tary weakness of the inhibitory centers, may be sufficient 
to produce epilepsy. In such cases, however,, the feeble 
inhibition is the important etiological factor, and diseases 
of the eye, throat, and nose are the strong exciting fac- 



246 NEUROTIC DISORDERS OF CHILDHOOD 

tors without which, in all probability, the epilepsy would 
not have developed. In the early history of such cases 
as these the removal of the reflex factor may cure the 
epilepsy; but later, when the epileptic habit is well 
established, the removal of the important etiological 
reflex factor may diminish the number of attacks, but 
does not cure the epilepsy, since inhibition has now 
become so feeble in these cases that slight, unavoidable 
reflex factors may excite a paroxysm. The fact that the 
removal of the exciting cause cures the epilepsy does not 
prove that this cause was the underlying factor of the 
epilepsy. It only proves that the all-important factor of 
feeble inhibition was not, in this particular case, impor- 
tant enough to produce epilepsy without the aid of a 
strong and constantly acting reflex factor. 

Among other important exciting causes of epileptic 
paroxysms may be mentioned intestinal irritation from 
undigested food, worms, or foreign bodies in the intes- 
tinal canal, diseases of the genito-urinary tract, such as 
stricture, adherent prepuce, and stone in the kidney; 
laryngeal irritation, fright, deficient oxygenation of the 
blood from remaining in over-crowded rooms, masturba- 
tion, sexual excess, heat stroke, and menstruation. Men- 
struation is, in fact, one of the most important of all of 
the exciting causes. In many cases there is always a 
recurrence of the epileptic attack at or near the menstrual 
time. 

SYMPTOMATOLOGY 

There are two distinct types of epilepsy. The major 
attacks, or grand mal, are characterized by a sharp cry, 



epilepsy 2 47 

loss of consciousness, a fall, and tonic convulsive move- 
ments, quickly succeeded by general clonic convulsions. 
The convulsive movements last for a few minutes and 
are followed by a profound sleep, which may continue 
for an hour or two. From this sleep the patient awakens 
convalescent from the attack and with little or no knowl- 
edge of what has happened. 

The minor attacks, or petit mat, are characterized by 
sudden loss of consciousness of short duration, sometimes 
only momentary, and by slight local convulsive move- 
ments, which may be confined to the fingers or face. 
These convulsive movements are often so slight as to 
escape attention. The patient recovers himself almost 
immediately, and is usually conscious that an interval 
of unconsciousness has passed. 

Both unconsciousness and convulsive movements, be 
they ever so slight, are necessary parts of both clinical 
types, and the habitual recurrence of these symptom 
groups stamps the disease as epilepsy. Between these two 
extreme types we may have great variation in the severity 
of these two constant symptoms, and these gradations, 
with the less characteristic symptoms that mark the indi- 
vidual attacks, give great variety in symptom grouping 
to epileptic seizures. 

Aura. — The grand mal attacks may occur suddenly 
without warning symptoms, but as a rule they are pre- 
ceded by certain prodromes known as aura. The aura 
in the Jacksonian type of epilepsy may be motor, such 
as a local spasm of the face, hand, or leg; or they may 
be sensory, presenting some disturbance or sensation in 
the same parts of the body. As a rule, a numbness or 



248 NEUROTIC DISORDERS OF CHILDHOOD 

tingling sensation precedes the local spasm, and the 
convulsive movements are first unilateral and then 
become general. 

In toxic epilepsy the aura may be vertigo, hemian- 
opsia, light and dark spots, or flashes of light before the 
eyes ; a sensation of fullness in the head, or nausea. 

In developmental epilepsy the aura may be a vague 
sensation in the stomach, a feeling of numbness or 
tingling in the extremities, general restlessness, irrita- 
bility of temper, aphasia, a dazed, dreamy condition, or 
the ocular phenomena above noted. 

The prodromal symptoms, however, to the grand mat 
attacks of epilepsy are so varied that each individual 
comes to recognize his own particular aura. In many of 
these cases the patients learn by experience to heed these 
warning symptoms, and seek safe quarters before the 
onset of violent symptoms. 

Loss of consciousness, which is the most characteristic 
symptom of the epileptic attack, has strange variations in 
its manifestations. In certain cases dream-like states 
with partial loss of consciousness may immediately pre- 
cede the attack, and may continue for a number of days 
following the attack. When suddenly the patient re- 
covers consciousness, he may find a number of days or 
weeks have passed and made no imprint on his memory. 

The convulsion, which is the next most characteristic 
symptom of the epileptic attack, varies greatly in severity 
and character. The violence of the convulsion may be 
so great, in rare instances, as to break bones and cause 
painful bruises, and, on the other hand, it may be so 
slight in the petit mal attacks that the momentary twitch- 



EPILEPSY 249 

ings of the muscles of the face or hands may not be 
observed at all. The convulsion may be general in 
character from the onset, as is the rule in developmental 
and toxic epilepsy, or it may, as in organic epilepsy, be 
partial, confining itself to one member of the body or to 
one-half the body, or it may begin as a local and later 
become a general convulsion. 

In severe general epilepsy the pupils are dilated, there 
is no reaction to light, there is more or less spasm of the 
muscles of respiration, producing cyanosis and irregu- 
larity of the respiratory rhythm ; the face may be bloated 
and distorted; spasm of the muscles of the jaw may 
result in biting of the tongue, so that the froth which 
exudes from the mouth during the paroxysm may be 
tinged with blood ; and involuntary passages of urine and 
faeces commonly occur. At the beginning of the 
paroxysm the face may be pale; later it may be dark 
and congested. 

In the petit mat attacks the loss of consciousness is 
often so slight that they are mistaken for " spells " of 
various kinds, such as dizziness, fainting turns, or con- 
scious tricks. But these attacks, be they ever so mild, 
are none the less serious in character, and are, as a rule, 
accompanied by a complete change in the child's mental 
condition; it becomes more irritable, and sometimes a 
mild form of mania is developed. 

As previously noted, the habitual recurrence of these 
attacks stamps the condition as epilepsy. The recurrence 
of attacks, however, is in most cases extremely irregu- 
lar, except in those cases where menstruation is so im- 
portant an exciting cause as to produce regular monthly 



2 50 NEUROTIC DISORDERS OF CHILDHOOD 

attacks of epilepsy. In these cases we sometimes have 
not only regular attacks of menstrual epilepsy, but also 
intermenstrual attacks, occurring half-way between the 
menstrual periods. In most cases, however, the attacks 
are very irregular. A number of attacks may occur 
within twenty-four hours, and then an interval of days, 
weeks, or months may elapse before another attack 
occurs. 

In those cases in which there is progressive degenera- 
tion of mental faculties, there is a tendency to increase 
in the frequency of attacks. In certain cases the epilepsy 
may occur during sleep, and never during the waking 
hours. In these purely nocturnal cases there is some- 
times great difficulty in diagnosis, if the patient occupies 
a bed and room alone. In some of these cases, however, 
biting of the tongue may produce blood upon the pillow ; 
or incontinence of urine and faeces, followed the next 
morning by a sense of lassitude, mental dullness and 
headache, may lead one to suspect nocturnal epilepsy, and 
the diagnosis may be made by having an attendant sleep 
with the patient. 

Procursive epilepsy is rather a rare form in which the 
symptoms of petit mal are associated with strange 
running movements. 

Mental Symptoms. — In nearly all cases of epilepsy, as 
the disease progresses, there is more or less mental 
impairment. In the purely toxic forms of the migrain- 
ous type there may perhaps be little or no loss of mental 
capacity. The mental symptoms of organic epilepsy will 
depend altogether upon the location and extent of the 
organic disease. Well-marked mental impairment is the 



EPILEPSY 251 

rule, however, even in the milder cases of this type. 
Some of the more severe cases are congenital idiots. 

In the great group of epileptics belonging to the de- 
velopmental class, progressive mental impairment, with a 
tendency to the development of idiocy, melancholia, or 
mania, is common. As a rule, however, these children 
fail to develop mentally, maintaining their childish intel- 
ligence throughout life. In a large group, however, the 
mental development may be simply retarded, so that the 
child is considered backward, but not otherwise mentally 
deficient. 

Associated with the melancholia which develops in 
some of these cases there may be a peculiar cunning 
which enables the epileptic to commit acts of violence, 
even murder, and so cover his tracks as to avoid 
suspicion. 

Associated with organic epilepsy we not infrequently 
have disturbances of speech and slight degrees of spastic 
palsy. 

DIAGNOSIS 

There is little difficulty in recognizing an attack of 
grand mat. These cases can scarcely be confused with 
anything except hysteria. In hysteria, however, the 
warning cry is absent, the loss of consciousness is not, as 
a rule, absolute, the pupils are not dilated, the eyes, in- 
stead of being turned upward and inward, stare into 
vacancy, there is no involuntary passage of urine and 
faeces, and there is no prolonged sleep following the 
attack. In some cases, however, we may have a queer 
combination of hysteria and epilepsy, but these cases 



2 52 NEUROTIC DISORDERS OF CHILDHOOB 

are comparatively rare in this country, although they 
seem common in France. 

In the diagnosis of petit mat there is probably greater 
difficulty, because of the inability or disinclination on the 
part of the mother to accurately describe these attacks. 
She is much inclined to minimize these symptom groups, 
and to speak of them as " spells." The physician, there- 
fore, must attach special importance to the marked 
change in temperament and irritability which has oc- 
curred since these " spells " made their appearance. 

Great importance attaches to the differential diagnosis 
of the various types of epilepsy. 

In organic epilepsy there is, as a rule, little difficulty 
if the physician will carefully search for evidences of 
organic disease of the nervous system. If Sachs' advice 
is followed, to test in every case the comparative strength 
of the muscles of the right and left hand, and to search 
for an exaggeration of deep reflexes, as well as to inquire 
carefully into the early history of the child for evidence 
of disease of the nervous system, many cases that have 
been classed as developmental will be found to be organic. 
Partial convulsions, which may or may not become 
general, also indicate organic epilepsy. 

When epilepsy develops suddenly in older children who 
have been previously healthy, one should suspect, accord- 
ing to Sachs, " the possibility of an intercranial tumor ; 
and a slight weakness of the part convulsed, a possible 
increase of the deep reflexes in the same part, the pres- 
ence of headaches and the development of optic neuritis 
are the symptoms which we must look for in order to 
establish or to discard the diagnosis of tumor." 



EPILEPSY 2 53 

Toxic Epilepsy. — In this form the diagnosis is made 
by the late occurrence of the disease, the family history 
of gout and migraine, the previous personal history of 
migraine, the character of the urine, and the stomach 
and vasomotor symptoms which commonly accompany 
the attack. 

Menstruation is one of the most common of the 
exciting factors of toxic epilepsy, and all cases of men- 
strual epilepsy must, therefore, be carefully studied 
with reference to the possibility of their toxic origin. 
Mental impairment is not so marked in these cases as in 
other forms of epilepsy. 

Developmental Epilepsy is by far the most common 
of all types, and all cases that cannot be differentiated as 
organic or toxic must be included in this group. This 
form of epilepsy is invariably bilateral, or general in its 
manifestations. Nocturnal epilepsy belongs to this class. 
The convulsions occur at night in these cases because 
the voluntary inhibitory centers are asleep, and the feeble 
inhibition which is characteristic of these cases is thereby 
still further weakened. In this form of epilepsy also we, 
as a rule, have mental stagnation or mental impairment, 
and some of the stigmata of degeneration are usually 
present. These are the cases, also, in which we get 
almost invariably a well-marked neurotic history, and 
in probably more than one-third of the cases there is a 
family history of predisposition to epilepsy or some other 
convulsive disorder. The petit mal attacks, for the most 
part, belong to this class. But when attacks of petit mal 
are associated in the same patient with severe grand mal 
attacks, toxic epilepsy should be suspected. 



2 54 NEUROTIC DISORDERS OF CHILDHOOD 

PROGNOSIS 

The prognosis in organic epilepsy is always unfavor- 
able ; the severity, the nature, and the location of the 
organic disease will determine whether any hope is to 
be offered by operative treatment, as surgery offers 
almost the only hope for permanent improvement in 
these cases. A few, however, due to syphilis, may be 
improved by anti-syphilitic treatment. 

In toxic epilepsy, if not of too long standing, the 
prognosis is much more favorable, since many of these 
cases are benefited and a few of them cured by proper 
treatment. 

In developmental or idiopathic epilepsy the prognosis 
is, on the whole, bad ; yet a large percentage of these cases 
may be greatly improved and many of them cured by 
careful treatment. In cases where the epileptic symp- 
toms have lasted less than a year, and where a potent 
and removable reflex factor exists, the prognosis for 
permanent cure is good, and in those cases also where 
chronic malnutrition is a potent etiological factor the 
prognosis is not unfavorable. 

TREATMENT 

Treatment of Attack. — Where the aura precede the 
attack a sufficient length of time to permit of treatment, 
patients may be provided with pearls of nitrite of amyl, 
or with a mixture of equal parts of chloroform and 
nitrite of amyl, for inhalation as soon as the warning 
symptoms appear; in this way attacks may sometimes 



EPILEPSY 2 55 

be warded off. During the attack the patient should be 
protected from injury. Some foreign body should be 
placed between his teeth to prevent injury to the tongue, 
and violent spasmodic movements should not be re- 
strained. 

General Treatment. — Epileptics are very favorably 
influenced by suggestion; this may be a matter of envi- 
ronment, or a matter of medical or surgical treatment. 
Temporary improvement very commonly follows almost 
any change. Slight surgical operations, change of local- 
ity, any form of counter-irritation, or any new and prom- 
ising line of treatment, may suspend the attacks or 
lengthen the interval to months in cases where the 
interval has been days or weeks. 

In beginning the treatment it is important that a care- 
ful search should be made for exciting causes, which are 
usually reflex. Eye-strain should be corrected. Diseases 
of the nose and throat must have appropriate treatment, 
and an adherent prepuce or phimosis should be relieved 
by proper surgical measures. Many cases of epilepsy 
have been favorably influenced and not a few cases have 
been cured by the removal of reflex factors having their 
origin in diseases of the eye, nose, throat, and genito- 
urinary organs. 

Since Herter and Smith called attention to the im- 
portant role which intestinal toxaemia might play as a 
contributing factor in epilepsy, the profession has recog- 
nized the special importance of looking after the digestive 
tract in the treatment of every case.. Constipation must 
be overcome, intestinal intoxication must, if possible, be 
prevented, and reflex irritation from the intestinal canal, 



256 NEUROTIC DISORDERS OF CHILDHOOD 

such as may be produced by undigested food and worms, 
must be removed. To do this the diet of the patient must 
be carefully selected with reference to his age, idiosyn- 
crasies, and digestive capacity. 

As a rule, these patients may be allowed a general diet, 
avoiding alcohol, coffee, tea, sweets, salads, pastry, and 
an excess of albuminoids. , Milk, cereals, vegetables, 
fruits, and meats in moderate quantities may be allowed. 
An excess of food is especially injurious. 

In menstrual epilepsy, or in those cases in which the 
menstrual period is the exciting cause, the pelvic organs 
should be carefully inspected, and any diseases of the 
ovaries or uterus should be removed by appropriate 
treatment. 

It is of the very greatest importance to correct all 
forms of malnutrition. This is especially important in 
the early cases of developmental epilepsy. In cases of 
this kind of less than a year's duration the correction 
of nutritional disturbances may result in a cure. 

Chronic anaemia, or chronic malnutrition, whether pro- 
duced by tuberculosis, rheumatism, heart disease, chronic 
malaria, chronic disease of the digestive organs, heredi- 
tary syphilis, repeated attacks of influenza, or other acute 
infections, must receive appropriate treatment, since these 
factors are sometimes responsible for the development of 
epilepsy in predisposed individuals. 

The general hygienic treatment must be carefully 
looked after. As Jacobi says : " The child known to be 
epileptic must be trained very carefully, both physically 
and mentally. . . . Feeding with grewsome nursery 
stories, tight dressing, and early schooling, also horse- 



EPILEPSY 257 

back exercise and swimming, are forbidden. In the 
interest both of the patient and his schoolmates a public 
school should not be attended. The child ought to be 
instructed and trained with a view of preparing him for 
his future calling, which must not overstrain body or 
mind, must not be sedentary, nor should it confine him, 
if avoidable, to the limits and influences of city life 
and air." 

Medical Treatment. — The bromides are the most valu- 
able remedies we have in the treatment of epilepsy. This 
treatment is not simply palliative, but when combined 
with the general treatment above noted, it may be, in 
selected cases, curative. The curative effect of the bro- 
mides probably depends upon the fact that the epileptic 
habit is, by this treatment, interrupted, giving the general 
treatment, which is always combined with the bromide 
treatment, an opportunity to remove important factors 
of the disease. The bromide treatment, therefore, should 
be continued for a year or more after the paroxysms have 
ceased, or until nutritional faults are corrected, all excit- 
ing causes removed, and the patient's general health so 
improved that it (the bromide treatment) may gradually 
be discontinued without causing a return of the 
paroxysms. 

Strontium bromide is perhaps just as effective as any 
of the bromides, and it is much less irritating to the 
stomach. For these reasons it is the best of the bromides 
to use in the treatment of epilepsy in young children. It 
may also be used in adults where large doses of other 
bromides have produced stomach or intestinal irritation. 
Sodium and potassium bromides are, however, thor- 



258 NEUROTIC DISORDERS OF CHILDHOOD 

oughly reliable, and it is with these drugs that the 
bromide treatment of epilepsy has, by long usage, proven 
its efficacy. 

Bromides are to be given in large doses — 30 to 60 
grains per day for a child of six years. The dose should 
be large enough to control the paroxysms, where this is 
possible. It is best that they should be given, as Seguin 
suggests, in large doses shortly before the expected parox- 
ysm. In nocturnal epilepsy one large dose (one-half to 
two drams, very largely diluted) taken at bedtime. In 
other periodic forms the greater part of the daily dose 
is to be taken shortly before the time of the expected 
paroxysm. In menstrual epilepsy large doses are to be 
given just before and during the menstrual period, and 
smaller doses continued throughout the interval. 

Hydrobromate of hyoscine (1-100 to 1-200 of a grain) 
may be given three times a clay with great advantage in 
connection with the bromide treatment. 

Belladonna is to be especially recommended in combi- 
nation with the bromides in all those cases where there 
is any suggestion of gastro-intestinal irritation. Borax 
has also been recommended in 5 to 20 grain doses, 
combined with the bromides in these cases. 

Chloral and antipyrin may be used in connection with 
the bromide treatment, to get control of the paroxysms 
in severe cases, but these drugs are not to be continued 
for any length of time in the treatment of epilepsy. 

Fleching advises a combination of opium and bromides 
for the control of the paroxysms. He begins with one- 
half to one grain of opium per day, and gradually in- 
creases until the patient is taking 10 or 15 grains. After 



EPILEPSY 259 

six weeks the opium is stopped suddenly and large doses 
of the bromides substituted, and thereafter continued in 
the treatment of the case as long as sedative treatment is 
necessary. 

Arsenic, in small doses, may prevent or cure the acne 
which develops from the bromide treatment. 

Digitalis may be used when disease of the heart is 
thought to be a contributing factor in producing the 
epilepsy. 

In the treatment of toxic epilepsy of migrainous origin, 
in addition to the above treatment the patient is to be 
given the systematic treatment for migraine as outlined 
in Chapter XV. In these cases cannabis indica is, next 
to the bromides, by far the most valuable remedy we 
have for preventing the paroxysms. 

In the treatment of organic epilepsy, in addition to the 
above treatment, surgical measures may be of value. 

The surgical treatment of epilepsy, that at one time 
seemed to promise so much and attracted such wide- 
spread attention, has, to say the least, been a great disap- 
pointment. The surgical treatment of organic epilepsy 
seems altogether rational, and no doubt more cases would 
be benefited if surgical interference were resorted to 
earlier. But these cases rarely fall into the surgeon's 
hands until medical and other treatments have proved 
inefficient. 

Sachs very clearly sums up our knowledge of this sub- 
ject as follows : " In a case due to a traumatic or organic 
lesion, an early operation may prevent the development 
of cerebral sclerosis. If early operation is not done, the 
occurrence of epilepsy is a warning that secondary 



26o NEUROTIC DISORDERS OF CHILDHOOD 

sclerosis has been established, and an operation may 
prevent it from increasing. Operation must include the 
removal of the diseased area ; here, if all other parts are 
normal, a cure may result. Under favorable conditions 
a few cases of epilepsy may be cured by surgery, and 
many more improved." 

Sachs further says : " I consider it important not to 
wait the actual development of epilepsy ; and if the brain 
has sustained any considerable injury, to remove the 
injured tissues, which, if allowed to remain, constitute a 
permanent menace to the future health of the patient. 
We shall be able to prevent development of epilepsy 
very much more readily, than we can cure it if once 
established." 



CHAPTER XVIII 

RECURRENT CORYZA 

There is a form of coryza, recurring at irregular 
intervals without apparent local or external cause, which 
is self-limited and appears to be closely related in its 
etiology and pathology to recurrent vomiting; for this 
reason I have used the term Recurrent Coryza to describe 
this condition. 

ETIOLOGY 

Heredity. — There is, as a rule, a distinctly neurotic 
family history, and there is almost always a family his- 
tory of gout or migraine. This syndrome is, in fact, 
often associated in the same patient with recurrent vomit- 
ing or migraine. The hereditary factor, therefore, in 
this condition is very important, and very closely allied 
to recurrent vomiting and migraine. 

Age. — These cases are more common during childhood 
than during adult life. 

Constipation is almost always present, and is an im- 
portant etiological factor. The constipation probably 
acts by producing a sluggishness in the action of the 
liver and a gastro-intestinal toxaemia. 

Toxins, either auto or intestinal in origin, are believed 
to be the all-important causative factors in the production 
of this neurosis. The auto-toxins of the gouty diathesis 
which, as I believe, are etiologically related to migraine 

261 



262 NEUROTIC DISORDERS OF CHILDHOOD 

and recurrent vomiting may produce this syndrome by 
their action on the vasomotor nerves supplying the 
mucous membranes of the nasal passages and eyes. In- 
testinal toxins, such as commonly find expression in 
urticaria and other vasomotor phenomena, may also be 
etiologically related to these attacks of recurrent coryza. 
What determines this portion of the vasomotor nervous 
system as the point of attack for these poisons is not 
altogether clear, since in most instances the exciting 
causes of the attack are not apparent. In a minority of 
the cases it may be that a special instability of the vaso- 
motor nerve supplying the parts attacked has been devel- 
oped by some local irritation in the throat, nose, or eye. 

SYMPTOMS 

Constipation, loss of appetite, general nervous irrita- 
bility, and sallowness of skin may be prodromes to an 
attack of recurrent coryza. 

The attack itself comes on with an acute congestion of 
the nasal mucous membrane, accompanied by a profuse, 
irritating, thin mucous discharge from the nose, which 
produces redness and swelling of the lip over which it 
flows ; at the same time there is commonly an acute con- 
gestion of the mucous membranes of the eyes, marked by 
a redness and swelling of the conjunctiva, intense photo- 
phobia, and a profuse overflow of tears. These symp- 
toms come on rapidly and produce a state of extreme 
general nervous irritability. The patient seeks a dark- 
ened room and buries her head in the pillows or shields 
her eyes with her hands when any light is admitted. 



RECURRENT CORYZA 263 

These attacks are self-limited. The symptoms continue 
in the worse cases for four or five days, and then quickly 
subside. The convalescence is very rapid ; within two or 
three days after the symptoms begin to disappear the 
patient is quite well, showing little or no evidence of 
disease of the mucous membranes, which were so recently 
the site of such extreme irritation. These attacks may 
recur from time to time at irregular intervals, very like 
those of migraine and recurrent vomiting, and in the 
interval between the attacks there may be no evidence of 
disease of the mucous membranes of the eye and nose. 

The above description represents the severe type of 
this disorder. In milder cases the attack may manifest 
itself as a more or less severe coryza without the eye 
symptoms, and may, in this form, occur as one of the 
prodromes of an attack of recurrent vomiting. Vaso- 
motor coryza is also not uncommonly associated in its 
clinical manifestations with an urticaria of the skin. 

The urine passed during a severe attack of recurrent 
coryza is highly colored, strongly acid in reaction, 
scanty, of high specific gravity, and contains an excess 
of the purin bodies. 

Podiatrists have given little or no attention to these 
cases; they are, however, described by laryngologists 
under the titles " Vasomotor Coryza " and " Periodic 
Hypersesthetic Rhinitis." Lenox Browne speaks of these 
cases as being caused by "sensitive spots in the nose, 
with a vasomotor debility and some local irritant as 
cooperative factors." Kyle says that " they may be due 
to a local irritant acting from without, usually of 
botanic origin, or to local irritation from an internal irri- 



264 NEUROTIC DISORDERS OF CHILDHOOD 

taut, such as uric acid. . . . The form due to the 
rheumatic or gouty diathesis is more amenable to treat- 
ment than any of the other varieties." And for these 
cases he prescribes water, sodium phosphate, lithium, and 
Basham's Mixture. 

TREATMENT 

Treatment of the Attack. — Local treatment is of little 
avail; in severe cases, however, a spray of cocaine and 
adrenalin chloride may be tried. Bromide of potash and 
tincture of belladonna, in doses to suit the age of the 
child, should be given throughout the attack. This seda- 
tive medication relieves the general nervous irritability 
and makes the child more comfortable until the self- 
limited attack has run its course. Medicines, perhaps, 
have little influence in shortening these attacks. One- 
fourth grain doses of calomel, combined with five grains 
bicarbonate of soda, should be given until six or eight 
doses are taken, and this should be followed by a saline 
cathartic, preferably the sulphate of magnesia. 

In the interval between the attacks the bowels are to 
be kept open with sulphate or phosphate of soda, which 
may be dissolved in elixir of teraxicum or some other 
palatable vehicle. A dose of these medicines sufficient 
for the purpose may be taken at bed-time or on arising 
in the morning. In the majority of cases this simple 
medication will suffice to prevent a recurrence of these 
attacks. Patients, however, who fail to respond to this 
treatment may be given, in addition, fivt to eight grains 
of benzoate of soda, dissolved in essence of pepsin, after 
luncheon and dinner. The dietetic treatment is important. 



RECURRENT CORYZA 265 

Tea, coffee, sweets, and an excess of red meats are to be 
avoided, but milk, cereals, vegetables, cooked fruits, 
chicken, fish, and eggs, and a moderate amount of fresh 
red meat may be allowed. 

These children should also be protected from nervous 
strain and excitement, and should be encouraged to lead 
an active outdoor life. 



AUTUMNAL CORYZA 

Autumnal coryza, or hay-fever, is a form of periodic 
coryza occurring in the late summer months. It is most 
severe from the middle of August to the middle of 
September. The attack, as a rule, lasts from five to six 
weeks, and during this time the patient either suffers 
continuously from the coryza or has recurring attacks, 
the length and severity of these attacks depending upon 
the exposure to the exciting causes and to the intensity 
of the hereditary predisposition. This disease is rare in 
young children; it is seen, however, not infrequently 
after the tenth year. Its manifestations in the child do 
not differ in any way from those in the adult, and it is 
here noted only for the purpose of differentiating it from 
recurrent coryza. 

ETIOLOGY 

Heredity is a strong factor in producing this disease. 
A neurotic or gouty family history is commonly found, 
and a family history of hay-fever is not infrequent. 

Auto-toxins are believed by many writers to play an 
important role in the production of autumnal coryza, but 



266 NEUROTIC DISORDERS OF CHILDHOOD 

in the present state of our knowledge we know little of 
the character of these toxins. Many writers believe that 
they are closely allied to the auto-toxins of the gouty 
diathesis. 

Diseases of the throat, and especially of the nose, are 
exciting factors which tend to aggravate, prolong, and 
precipitate attacks of autumnal catarrh. 

There can be no doubt, however, that the most 
important of the exciting causes come from 'without, in 
the nature of irritants received by inhalation, the most 
important of which are furnished by plant life in the 
nature of pollen. In this regard hay-fever differs radi- 
cally from recurrent coryza, which is apparently brought 
on by toxins formed within the body. 

SYMPTOMS 

The symptoms of autumnal coryza are very much like 
those of recurrent coryza. In the former the catarrhal 
inflammation of the nose, eyes, throat, and bronchi is a 
more or less chronic condition extending over a period 
of weeks. The attacks are not self-limited, but depend 
for their duration and severity upon atmospheric changes 
and the presence of certain irritants in the inspired air. 

TREATMENT 

The local treatment of the upper air passages with 
solutions of cocaine and adrenalin gives great relief. 
But a change of location to an atmosphere that does not 
contain the irritants which excite the paroxyms is the 



RECURRENT C0RY2A 267 

only successful means of controlling" the attack. By 
removal to suitable localities the attack may be entirely 
relieved or greatly modified. The patient may return 
home with safety, as a rule, after the first general frost, 
which is believed to destroy the pollen, or vegetable 
matter, the presence of which, in the atmosphere of a 
locality, will excite the disease in susceptible individuals. 



CHAPTER XIX 

A CLINICAL STUDY OF CASES ILLUSTRATING THE KINSHIP 
OF RECURRENT VOMITING, RECURRENT CORYZA, TOXIC 
EPILEPSY, AND MIGRAINE 

Migraine is by far the most common of the above- 
named syndromes, and in previous chapters I have noted 
the close relationship which exists between each of these 
symptom groups and the migrainous diathesis. It is 
my belief, as previously expressed, that true migraine is 
essentially an auto-intoxication, and that the same auto- 
toxins which produce migraine may also be responsible 
for recurrent vomiting, recurrent coryza, and one form 
of toxic epilepsy (migrainous epilepsy). 

I am not prepared to discuss what determines the par- 
ticular syndrome to be developed in any given case further 
than to say that these poisons, acting largely through the 
sympathetic nervous system, may develop any one of the 
above-named syndromes by attacking different parts of 
this nervous system. The central nervous system of the 
same part is also more or less under the influence of these 
poisons. I do not mean to say that migraine, recurrent 
vomiting, recurrent coryza, and toxic epilepsy are always 
produced by the same auto-toxins. It is not probable that 
any one of these symptom groups has one essential etio- 
logical auto-toxic factor without which they cannot de- 
velop. It is much more probable that the essential etio- 
logic toxic factor may vary in all of them. But I do 

268 



A CLINICAL STUDY OF KINDRED CASES 269 

believe that the most potent etiologic factors of a large 
percentage of the cases of recurrent vomiting, recurrent 
coryza, and migrainous epilepsy are auto-toxins either 
identical with or closely related to the toxins which are 
responsible for most of the cases of migraine. 

The following cases are selected from my notebooks 
for the purpose of illustrating the kinship of these dis- 
eases : 

Case 1. — Male, aged 8. A strong family history of 
gout on both sides for several generations. Mother and 
maternal grandmother suffer frequently and severely 
from migraine. Father also has migraine, and occasional 
bilious attacks characterized by pain in the stomach, with 
nausea and vomiting. 

In December, 1896, I saw this patient, then five months 
old, in a typical attack of recurrent vomiting. At that 
time I learned from his mother that he had suffered from 
similar attacks at intervals of four to six weeks since he 
was two months old. The earlier attacks were thought 
to be due to bad milk, but as they had recurred under the 
most careful feeding, and as the same symptom group was 
repeated each time, I was convinced that the attacks were 
constitutional in origin, and referred to them as attacks 
of " Lithaemic Vomiting." 

Following the December attack the child took and di- 
gested his food perfectly; his stools were normal in color 
and consistency, and he gained steadily in weight until 
his next attack, on February 8. This attack having been 
predicted, its symptoms were carefully noted, and as it is 
the youngest case of recurrent vomiting I have ever seen, 
they are here given in more or less detail. (This case 



270 NEUROTIC DISORDERS OF CHILDHOOD 

was published in 1897 in the Archives of Pediatrics, un- 
der the title " Lithsemic Vomiting.") 

Feb. 8. Infant refused food, vomited at 1 p. m. Feb. 
9, continued to take only small quantities of food, again 
vomited at 1 p. M. Feb. 10, restless and fretful all night, 
vomited at 4 A. M. During the day he was nauseated 
and refused food — evening temperature 102. Feb. 11, 
nausea continued. He vomited at intervals all night, 
has retained nothing on his stomach; appears very ill; 
temperature 102; nausea and vomiting continued during 
the day; evening temperature 103.5; nas na d 1-20 of a 
grain of calomel every hour since morning. Feb. 12, 
cried all night; took no food; nausea and vomiting con- 
tinued; breath had acetone odor; temperature 102. He 
has wasted to a skeleton, and appears critically ill. Dur- 
ing the afternoon and evening calomel and water were re- 
tained. 

Feb. 13. He retained a little dilute cream last night, 
the first in sixty hours ; bowels moved at 4 and 6 a. m. ; 
putrid movements; temperature 101. During the day 
he retained small quantities of cream mixture. Feb. 14, 
very much better ; temperature normal ; took and retained 
his milk. From this time on convalescence was uninter- 
rupted. 

These attacks recurred at intervals of one to six months 
during the next five years, varying little in character 
during this time ; but when he was about six years of age 
he commenced to have headache with these attacks of 
vomiting, and for the last two years he has suffered at 
intervals of every two or three months with typical at- 
tacks of migraine. The headache in these attacks is very 



A CLINICAL STUDY OF KINDRED CASES 27 1 

severe, is unilateral, lasts from twelve to twenty-four 
hours, and is associated with nausea and vomiting. 

I have followed this patient's clinical history and ob- 
served him frequently during these years, and there can 
be no question that in this instance attacks of typical 
recurrent vomiting have been transformed into attacks of 
typical migraine. 

Case II. Male, aged 10; a brother of Case I. When 
about two years of age he commenced to have attacks of 
recurrent vomiting, characterized by obstinate constipa- 
tion, fever, nausea, and persistent vomiting. The nausea 
and vomiting would continue for three or four days, and 
would then disappear as suddenly as they came, and in a 
few days all stomach symptoms would disappear. These 
attacks came and went without apparent cause, and the 
mother soon learned they were self-limited, and that she 
might expect their recurrence every six or eight weeks. 

When this boy was five years of age these attacks 
of recurrent vomiting commenced to change into attacks 
of migraine, and at the present time he still suffers from 
severe and typical attacks of true migraine; nausea and 
vomiting always accompany them. Within the last two 
years he has had two attacks of recurrent vomiting 
(without headache), lasting four or five days; so that in 
this boy the attacks of migraine are still occasionally 
supplanted by attacks of recurrent vomiting. 

With this case, as with Case I, I have personally ob- 
served the change in the character of the attacks, and I 
am therefore quite sure that in both of these cases at- 
tacks of recurrent vomiting, later in the life of the child } 
became attacks of true migraine. 



272 NEUROTIC DISORDERS OF CHILDHOOD 

Case III. Female, aged 16, neurotic family history; 
patient herself extremely neurotic and malnourished. She 
had suffered from attacks of recurrent vomiting since 
she was a small child, and in the last few years these at- 
tacks had occasionally alternated with attacks of severe 
migraine, in which nausea and vomiting were marked 
features. I saw this patient in consultation on the sixth 
day of an attack of recurrent vomiting, in which the 
nausea was continuous and the vomiting so severe that 
morphine had been used hypodermically. Calomel and 
soda were given by the mouth, and high rectal injections 
of salt water every six hours. On the seventh day the 
patient commenced to convalesce, and recovered from this 
attack, as she had from all others, quite rapidly. 

Following this attack, which occurred in the early 
spring of 1900, she went to the seacoast of Maine and 
there spent the summer. The following winter was spent 
in Southern California, and when I last heard from her, 
one year after her attack, she was well and had remained 
so throughout the year. 

Case IV. Female, aged 24, a neurotic and alcoholic 
family history, suffers severely from attacks of true mi- 
graine, nausea and vomiting being prominent features. 
She gives a personal history of having suffered from at- 
tacks of nausea and vomiting during her childhood. 
These attacks were very severe ; they occurred at irregular 
intervals, and lasted from three to six days. She was 
well in the interval between these attacks of "gastritis." 
For the past four years she has not had an attack of re- 
current vomiting, but during this time has suffered at 
intervals from migraine, and she herself associates the 



A CLINICAL STUDY OF KINDRED CASES 273 

disappearance of the " vomiting attacks " with the ap- 
pearance of the " sick headaches " from which she now 
suffers. 

Case V. Reported by me in the Medical Record, June 
22, 1895, under the title "Migrainous Gastric Neurosis.'' 
Mrs. P., age 43, mother of four children; her mother and 
a number of her family have suffered from sick head- 
aches. She has had migraine ever since she was a child. 
In recent years these attacks have occurred every two or 
three weeks, and were marked by the characteristic uni- 
lateral headache, accompanied by nausea and vomiting. 
In the interval between the attacks she was well. In 
1895, when she was 34 years of age, the attacks of 
migraine ceased, and were superseded by severe gastric 
attacks, which recurred every two or three weeks, as the 
migrainous attacks had previously done. These gastric 
attacks would come on with pain in the stomach, eructa- 
tion of gas, and a red spot would appear on the left cheek, 
with a sensation of burning. These warning symptoms 
were very soon followed by increase in the gastric pain, 
constant nausea, and uncontrollable vomiting, but no pain 
in the head. These symptoms would continue for two or 
three days, or until they were relieved by hypodermic 
injections of morphine. After the acute symptoms had 
subsided, the convalescence was uninterrupted and, as a 
rule, rapid, so that in a few days she was as well as usual, 
having no symptoms on the part of the stomach until the 
next gastric attack, which occurred two or three weeks 
later. 

Attacks of this character continued for about eight 
months, and during this time she had no migraine. When 



2 74 NEUROTIC DISORDERS OF CHILDHOOD 

suddenly, without apparent cause, the gastric attacks dis- 
appeared and attacks of true migraine began to recur 
every two or three weeks, and they have continued up to 
the present time. 

In Cases III and IV attacks of recurrent vomiting 
were transformed into attacks of true migraine, and 
in Case V attacks of migraine were transformed into at- 
tacks of Leyden's " periodical vomiting'' and the vomit- 
ing attacks were again transformed into attacks of mi- 
graine. It is not altogether clear to my mind that Ley- 
den's u periodical vomiting" is not closely related to 
recurrent vomiting. I am rather inclined to believe that 
attacks of recurrent vomiting occurring in the adult 
may be associated with severe gastric pain, and thus be- 
come the periodical vomiting of Ley den. However this 
may be, the case above reported is one of many reported 
instances in which migrainous attacks have been trans- 
formed into attacks of " periodical vomiting" and vice 
versa. And the fact that periodical vomiting (Leyden) 
and recurrent vomiting may both be transformed into 
attacks of migraine indicates that these syndromes may be 
produced by the same etiological factors. 

Case VI, which was referred to me by Dr. A. W. 
Johnstone, in 1899, was one of the most interesting and 
instructive it has been my good fortune to see. This 
case at different periods in her life suffered from recur- 
rent vomiting, migraine, and epilepsy, and is here re- 
ported in detail: 

E. X., female, aged 18. Family history. — Tuberculo- 
sis in one of the grandparents. Her grandmother on the 
mother's side suffered from recurrent gastric attacks, 



A CLINICAL STUDY OF KINDRED CASES 275 

which continued for many years and were called 
" bilious." They were characterized by nausea, uncon- 
trollable vomiting, and severe pain in the stomach. They 
would come on suddenly, completely prostrating her, and 
for five or six days she would not be able to retain any- 
thing on her stomach. She would then gradually im- 
prove, but would not be entirely well for four or five 
weeks. Then would follow a period of perfect health, 
during which time she ate all kinds of food and had per- 
fect digestion. She would continue well for four or five 
months, and then become prostrated with another gastric 
attack having the same symptoms as before. She con- 
tinued to have two or three of these attacks a year for nine 
or ten years, and during this time her physicians predicted 
that she would be better after the menopause. This pre- 
diction proved true, and for nine years she did not have 
an attack. At the age of 58, however, she had a 
severe gastric attack similar to the one previously de- 
scribed. This was followed after two years by another 
one, which caused her death. This death occurred at the 
time the mother of our patient was pregnant with the 
child whose history I am now relating. This and other 
domestic troubles caused the mother to be very nervous 
during her pregnancy, and probably increased the attacks 
of recurrent vomiting from which she also suffered. The 
mother of our patient continued to have paroxysmal gas- 
tric attacks of nausea and vomiting at intervals of a month 
or six weeks during the whole time of her pregnancy. 
Our patient, therefore, has the remarkable family history 
of " recurrent vomiting " in both the grandmother and 
mother. 



2?6 NEUROTIC DISORDERS OF CHILDHOOD 

On the father's side there is a very strong rheumatic 
family history. Two of his brothers are now suffering 
from " chronic rheumatism," while his father and one of 
his brothers died from chronic Bright's Disease. The 
father himself has pronounced gout, having attacks which 
are quite typical in character. During these attacks he 
suffers intensely from pain in the toes of both feet, es- 
pecially the big toes, and the joints are swollen and ten- 
der. He is confined to bed for two or three weeks at a 
time, and is then able to go about in perfect health until 
his next attack, some six or eight months later. His big 
toes are deformed with gouty deposits. 

Previous History. — Patient commenced to suffer from 
attacks of recurrent vomiting when she was a child. 
These attacks would come on without apparent cause, 
and would last three or four days, and be followed by 
rapid convalescence. From the description, they coin- 
cided in every particular with the description which I 
have previously given of recurrent vomiting. When she 
was about eight years of age these attacks commenced to 
be associated with pain in the stomach, and later with 
headache, and gradually they became attacks of true mi- 
graine, the headache being severe and the narcotism pro- 
nounced, while the gastric symptoms were not very 
marked, and after a time disappeared altogether. The 
migraine continued until she was about thirteen years of 
age, when the menstrual function appeared, and about 
this time the epileptoid attacks commenced. A year 
later the epilepsy was fully established, and the migraine 
had almost entirely disappeared. These epileptoid attacks 
in the beginning were very mild. It was at first noticed 



A CLINICAL STUDY OF KINDRED CASES ±77 

that she commenced to lose consciousness with her mi- 
grainous attacks, and gradually these attacks came to 
resemble true epilepsy. Epileptic attacks have continued 
up to the present time, and have no relation whatever to 
her menstrual periods. They occur every four or five 
days, and are characterized by a loss of consciousness, 
severe clonic spasm of the muscles, and frothing at the 
mouth. The patient sleeps for a few hours following the 
attack and then appears dazed for the remainder of the 
day. These attacks are now not associated with pain in 
the head, but they are at times accompanied by nausea or 
vomiting just before or after the attack. Within the past 
year these epileptic attacks have occasionally alternated 
with an attack of true migraine. She has been under con- 
stant medical treatment for five years, and during this 
time has taken a large amount of bromide of potash, and 
under this treatment has grown steadily worse, so that 
for the last two years she has been taught to believe that 
she is a confirmed invalid and has been treated as such. 
When she came under my care all medication was stopped 
and she was kept under close observation. 

Patient's Present Condition. — October 14, 1899. She 
is poorly nourished, undersized, and undeveloped. A 
physical examination by Dr. Arthur W. Johnstone re- 
vealed a general lack of development of the pelvic organs, 
but no organic disease. 

October 16. Her aunt, with whom she is now living, 
reported that she had an unusual appetite and took food 
in quantities more than sufficient to sustain a laboring 
man. I advised that her food be restricted in quantity, 
but otherwise nothing was done to ward off an attack. 



278 NEUROTIC DISORDERS OF CHILDHOOD 

October 24. At 2 a. m. she had a severe epileptic at- 
tack and was found lying on the bed partially dressed, with 
a large quantity of blood and mucus exuding from her 
mouth. When spoken to, however, she recovered con- 
sciousness and wished to get out of bed and have her 
breakfast. During the convulsion she lacerated her 
tongue quite badly and discharged a large quantity of 
urine involuntarily, completely emptying the bladder, and 
saturating her clothing and the bed. At 10 o'clock she 
drank a glass of milk, while still in bed. Half an hour 
later she complained of nausea, which was followed by a 
second epileptic convulsion. Following the convulsion 
she vomited a very sour, semi-solid mixture containing 
milk and other food. She remained in bed, but took no 
food. At 2 p. m. she had a third epileptic seizure. This 
was also followed by nausea and vomiting of half a pint 
of very acid, greenish fluid (bile). Following this third 
seizure there was considerable headache and a period of 
somnolence, such as followed the preceding convulsions. 
At 9 p. m. she had another convulsion, less severe than the 
others, but it was followed by a longer period of nar- 
cotism. She slept heavily for more than an hour, and 
awoke with nausea. Then followed a period of pro- 
nounced hysteria, which alarmed the aunt of the patient 
very much. She crawled about the bed, was very rest- 
less and nervous, and continued to be more or less ex- 
cited until she fell asleep at midnight, and slept quietly 
until morning. 

October 25. This morning I found her willing and 
anxious to get up. A saline cathartic, followed by an 
enema, had produced a free evacuation of the bowels; 






A CLINICAL STUDY OF KINDRED CASES 279 

very constipated. I ordered that she be kept in bed dur- 
ing the day, given milk to drink and a saline cathartic 
the next morning. 

October 26. Five p. m. I was called to the house by 
the aunt of my patient, who was greatly alarmed because 
she thought the girl was " going crazy." I learned that 
all of yesterday afternoon and all of to-day she had been 
in an extremely hysterical condition, and had alarmed her 
aunt by refusing to talk or to understand anything that 
was said to her. She would remain in bed apparently in 
a semi-conscious condition so long as her aunt would re- 
main in the room. If left alone, however, she would get 
out of bed and either talk incoherently or refuse to speak 
at all. She was caught, however, listening at the key- 
hole of her room to a conversation concerning her which 
was being carried on in the next room. When I saw her 
she was easily brought out of her hysterical condition, 
and was the next morning, October 2J, sent to a hospital. 

November 8. The patient has now been in the hospital 
eleven days, and during this time she has remained per- 
fectly well, except for a slight attack on November 3. 
This attack lasted only a few minutes, during which time 
the patient says she was unconscious. She was not, how- 
ever, convulsed. Immediately afterwards she got out of 
bed and seemed as well as usual. The nurse who wit- 
nessed the attack said that it did not last more than three 
minutes. Apart from this there have been no hysterical 
or other abnormal symptoms since she has been in the 
hospital, notwithstanding the fact that she has passed 
through a menstrual period while here. On going to the 
hospital she was given the following treatment: Milk 



280 NEUROTIC DISORDERS OF CHILDHOOD 

and bread diet at every meal, with the addition of an egg 
at breakfast, soup at dinner, and a baked apple at supper. 
The medical treatment has been a saline cathartic each 
morning, containing the sulphate, phosphate, and salicy- 
late of sodium, and one-quarter of a grain of cannabis 
indica three times a day. During the eight months this 
patient was under treatment she improved very much, 
both mentally and physically, and the epileptic attacks 
were less frequent and less severe. 

She returned to her home in a distant State, August, 
1900, and since that time I know little of her history ex- 
cept that the epileptic attacks have continued. 

This is the only case that I have ever seen presenting 
the three syndromes of recurrent vomiting, migraine, 
and epilepsy. The association, however, of epilepsy and 
migraine is so common, and so well recognized, that it 
would be a waste of time to narrate cases in which at- 
tacks of migraine have been transformed into attacks of 
epilepsy. In the Medical Record of June 22, 1895, I re- 
ported a case of this kind under the title " Migrainous 
Epilepsy." This case suffered from typical attacks of 
migraine for thirty or forty years, when the migrainous 
attacks ceased and epileptic attacks took their place, and 
they were continued for about ten years up to the time 
of her death, and during the period in which she suffered 
from epilepsy she had no attacks of migraine. 

Case VII. Male, aged 8, family history on father's side 
gouty, and on mother's side alcoholic and neurotic; one 
other child, a sturdy phlegmatic boy of five. 

Personal History. — Has had several severe attacks of 
gastro-intestinal trouble, and has always been nervous, 



A CLINICAL STUDY OF KINDRED CASES 28 1 

malnourished child. At five years of age had his first at- 
tack of recurrent vomiting, which was ushered in by a 
convulsion, associated with high fever; temperature dur- 
ing the first day of the attack ranged from 103 to 105. 
This attack lasted four days and was followed by a slow 
convalescence. These attacks have recurred at intervals of 
from two to six months up to the present time, and are, as 
a rule, marked by a single convulsion, which occurs 
during the first twenty-four hours of the attack. In the 
intervals between the attacks the patient is nervous, anae- 
mic, and has feeble digestion. The child is mentally pre- 
cocious. 

Case VIII. Male, aged 6. Neurotic family history on 
maternal side. The mother herself has suffered from mi- 
graine for years, and is markedly neurasthenic. 

Personal History. — The child has a poor physique, is 
intensely neurotic, and is below the average in mental de- 
velopment. Has been ill a great portion of his life. All 
of the many acute illnesses from which he has suffered 
since infancy have been marked by high temperatures, 
and, as a rule, by convulsions. He had many attacks of 
eclampsia during the first three years of his life. When 
about three years of age he had his first attack of recur- 
rent vomiting, during which he had three convulsive 
seizures. Since then has had two or three attacks of re- 
current vomiting each year, and they have always been 
associated with one or more convulsions and high fever, 
occurring during the first twenty-four hours of the attack ; 
after this the temperature subsided and the convulsions 
ceased, but persistent nausea and vomiting continued for 
from three to five days. With the disappearance of these 



282 NEUROTIC DISEASES OF CHILDHOOD 

symptoms the child convalesced rapidly, and was as well 
as usual in two or three days. 

In Cases VII and VIII we have eclampsia associated 
with attacks of recurrent vomiting. A case of this kind 
was reported by Snow in 1893. It is well, therefore, in 
the treatment of such cases, to keep in mind the kinship 
above noted of migraine, recurrent vomiting, and toxic 
epilepsy. It is possible that the recurring auto-intoxica- 
tions in these cases, producing repeated attacks of eclamp- 
isa, may -finally establish the epileptic habit, and in this 
way transform the attacks of recurrent vomiting into 
epilepsy. 

Case IX. (The corrected and completed history of a 
case reported by me in American Medicine, July 2j, 
1 90 1.) Female, aged 12. Her father suffers from mi- 
graine; her mother died of diphtheria when patient was 
but a few weeks old. 

Personal History. — There is no previous history of any 
serious illness, but she has always been nervous, and since 
she was five years old she has been subject to attacks of 
nausea and vomiting, coming on at intervals of two or 
three months. 

The nausea was continuous, the vomiting uncontroll- 
able, and the convalescence from these attacks of recur- 
rent vomiting was rapid and complete. Besides these at- 
tacks of recurrent vomiting the child, since she was six 
years of age, has had attacks of intense coryza. It was 
in one of these attacks that I first saw her in January, 
1899. I found her in a darkened room suffering so in- 
tensely from photophobia that I could not admit sufficient 
light to make a satisfactory examination. She was in a 






A CLINICAL STUDY OF KINDRED CASES 283 

state of extreme nervous irritability, which added to the 
difficulty of inspecting the case. I managed to see, how- 
ever, that the eyes were swollen, the nostrils intensely irri- 
tated, and that an abundant watery secretion was running 
from both eyes and nose, producing considerable irrita- 
tion of the lip and other parts over which it ran. I 
learned that the child had been taken suddenly ill with 
this attack about noon of the previous day, when she com- 
menced to complain of photophobia and nasal irritation, 
went to bed at once and remained in a darkened room. At 
the time of my visit, thirty hours after their onset, the 
symptoms had not abated in the least. I learned also that 
the many similar attacks from which the patient had suf- 
fered had lasted two or three days, at the expiration of 
which time she would get well as quickly as she got ill. 
'All pain, irritation, and hypersecretion from the eyes and 
nose would rapidly subside, and within a few days she 
would be at school again quite as well as before the 
attack. 

In the intervals between these attacks there was no 
trouble with the eyes and nose, and apart from being a 
nervous child, suffering somewhat from constipation, she 
was not considered unhealthy. She was quite equal to 
all the outdoor exercise incident to childish play, and went 
through her school work as easily as the average child. 
Of late these attacks have been more frequent and more 
severe, occurring at intervals of two or three weeks, while 
formerly, especially in summer, several months had 
elapsed between seizures. 

This very clear history of self-limited paroxysms of 
coryza, occurring in a young patient who had suffered 



284 NEUROTIC DISORDERS OF CHILDHOOD 

from frequent attacks of recurrent vomiting, and who had 
a family history of migraine, led me to the belief that 
the paroxysms of coryza were but another manifestation 
of the auto-intoxication which at times found expression 
in recurrent vomiting, the difference in the symptom 
groups produced being dependent upon the portion of the 
vasomotor nervous system attacked. 

Following this first attack I advised that she should 
have as much exercise in the open air as possible, and 
should avoid tea, coffee, sweets, and an excess of meats. 
That she should drink milk and eat cereals, vegetables, 
fruits, chicken, fish, eggs, and a moderate quantity of 
fresh meat. Her bowels were to be kept open with a 
mixture containing sodium sulphate, sodium phosphate, 
and lithium benzoate. Three weeks later the patient had 
a slight attack of coryza which lasted less than twenty- 
four hours. From that time to the present, more than 
five years, she has been kept under observation, and 
during this time has not had a severe attack of coryza. 
She has, however, suffered from a number of slight at- 
tacks, some of which were associated with mild attacks 
of recurrent vomiting, and recently she had one quite 
severe attack of recurrent vomiting, which was ushered 
in by an attack of coryza. 

Case X. Female, aged 7. Family History. — Mother 
has migraine, and one aunt on father's side had epi- 
lepsy. 

Personal History. — She was very well up to one year of 
age, when she weighed twenty-one pounds and ten ounces. 
Her first severe gastric attack occurred at this time, and 
lasted nine days. It was characterized by intense irrita- 



A CLINICAL STUDY OF KINDRED CASES 285 

bility of the stomach, no food, medicine, or water being 
retained. From that time to the present she has had 
similar attacks at intervals of from three to four months. 

At the present time her mother recognizes the ap- 
proach of an attack by the child's general nervous irri- 
tability, obstinate constipation, and facial pallor, with dark 
rings under the eyes. These symptoms are commonly 
accompanied by a slight coryza and whistling bronchitis 
(asthma). The first symptoms, on the part of the 
stomach, to appear are eructations of gas, and very soon 
thereafter the nausea and vomiting begin, and everything 
that the stomach contains is discharged. Intense nausea, 
with periodical attacks of vomiting, continue from four to 
nine days, and during this time no food, water, or medi- 
cine is retained; everything is rejected by the stomach 
almost as soon as it is swallowed. Throughout the at- 
tack there is a tendency to somnolence, and during the last 
days she sleeps most of the time. Following the cessa- 
tion of vomiting convalescence is rapid, and in twenty- 
four hours all stomach irritability has disappeared, and 
she is again taking malted milk and other light foods. 

In one very severe attack last winter she vomited con- 
siderable blood, enough to color all the vomited matter, 
and the retching and vomiting were so severe that she was 
at times profoundly cyanosed ; but just when she seemed 
utterly exhausted, and when her life was almost despaired 
of, the stomach irritability suddenly subsided and con- 
valesence from the attack was soon established. 

The constipation which preceded these attacks continues 
for a number of days, notwithstanding the calomel and 
enemata that are given, but towards their close the bowels 



2 86 NEUROTIC DISORDERS OF CHILDHOOD 

move, and for a few days there are two or three putrid 
discharges daily. 

There are two symptoms belonging to these attacks to 
which I wish to call especial attention. One of these is 
the somnolence which lasts throughout the greater por- 
tion of the attack, being especially prominent after the 
second day. The child from this time on sleeps not only 
all night, but also nearly all day. The sleep is, as a rule, 
not a heavy one, but becomes deeper towards the close of 
the attack, and a prolonged heavy sleep usually precedes 
the beginning of convalescence. 

The other symptom to which I wish to call attention is 
a slight coryza and whistling bronchitis which mark 
the beginning of nearly all of these attacks. These 
symptoms, as a rule, come on with the general nervous 
irritability, and precede the vomiting by one or two days. 
They, however, subside within two or three days after 
the vomiting begins. These symptoms are so pronounced 
that the physicians in attendance for a long time thought 
that the child had each time " taken cold," and that the 
medicines given for the coryza had produced the "gas- 
tritis " ; but as time went on it was evident that " the 
cold " was a part of the attack, and the coryza and whist- 
ling bronchitis are now recognized as ominous prodromes 
presaging an attack of recurrent vomiting. 

This patient is the daughter of a physician, and has 
been reared under good hygienic conditions. She has 
lived an outdoor life in country air, she has been put to 
bed at 7 p. m., and has slept all night; she has been 
protected from nervous strain and mental overwork, and 
notwithstanding these favorable conditions she has con- 



A CLINICAL STUDY OF KINDRED CASES 287 

tinued to suffer during her whole life from very severe 
attacks of recurrent vomiting. During this time, how- 
ever, her physicians, not recognizing the true nature of 
her malady, have treated her for gastritis due to " errors 
in diet" or "cold," and in their efforts to protect her 
stomach they have dieted and underfed her until they 
have added innutrition to the malnutrition from which 
she suffers. In the last few years her outdoor life has 
been greatly interfered with by the slow convalescence 
from the severe attacks and by the general feebleness of 
her constitution, which was thought to unfit her for ex- 
posure to any but the most clement weather. 

October 10, 1904. I saw this patient for the first 
time to-day, and obtained the above history. Her last 
severe attack was two weeks ago, and since that time she 
has been living on soup, toast, and malted milk. 

Present Condition. — Age 7, weight 52 pounds. She 
is thin, malnourished, precocious, and intensely nerv- 
ous. Her thin, pale face, large bright eyes, sprightly 
temperament, quick, nervous, restless movements, emaci- 
ated body, rapid heart action, and general feebleness of 
constitution mark her as a very ill child. 

The parents had come to look upon the child's condi- 
tion as hopeless, and were therefore much surprised when 
I made an uncompromisingly favorable prognosis. The 
following treatment was ordered : 

An outdoor life with a moderate amount of exercise, 
a minimum amount of mental work and all possible 
protection from nervous excitement; light general mas- 
sage, using plenty of lanoline, followed by one hour's rest 
in bed, every second afternoon. Diet: malted milk, cere- 



288 NEUROTIC DISORDERS OF CHILDHOOD 

als, eggs, stewed fruit, well-cooked vegetables and meat, 
either chicken or beef, at least once a day. 

Medical Treatment. — Phosphate of soda or Kutnow's 
Carlsbad Powder before breakfast each morning in a dose 
sufficient to move the bowels, and the following prescrip- 
tion to be taken three times a day: 

Sodii benzoatis . . 3 in 

Sodii salicylates (wintergreen) . 3 iss 

Essence of pepsin . . 3 vi 

M. S. — Teaspoonful in water after meals. 

r A glass or two of water was to be taken between meals, 
and the child was to go to bed at y p. m v after a light 
supper. If prodromal symptoms appeared, indicating an 
approaching attack, one-quarter of a grain of calomel and 
five grains of bicarbonate of soda were to be given every 
half-hour for six or eight doses, and followed two hours 
later by a dose of calcined magnesia sufficient to move 
the bowels. 

October 25. Is much improved in every way. She 
has gained three pounds in weight, and is much less nerv- 
ous, has a good appetite, and is taking a sufficient quantity 
of the prescribed foods. The first massage treatments 
were followed by a sensation of fatigue and general nerv- 
ousness, which lasted a greater part of the next day, but 
the recent treatments have had a tonic effect. 

November 8. Four days ago the mother thought she 
recognized signs of an approaching attack in the loss of 
appetite, constipation, odor of breath, and increased 
nervous irritability. She accordingly gave calomel, soda 



A CLINICAL STUDY OF KINDRED CASES 2 89 

and magnesia, as above directed, and these symptoms dis- 
appeared. Child continues to show improvement in her 
general condition, and has gained one pound. Treatment 
continued. 

December 3. Patient for two days has suffered from 
an acute coryza, such as almost always precedes her at- 
tacks of recurrent vomiting. This has been the only 
warning symptom of the attack, which commenced this 
morning with nausea and vomiting. Calomel, one- 
quarter grain, and sodium bicarbonate, six grains, were 
given every half-hour for eight doses; during this time, 
however, the vomiting occurred at intervals, so that per- 
haps little of the medicine was retained. 

December 6. The nausea and vomiting have con- 
tinued, no food or water has been retained by the stomach. 
Bicarbonate of soda has been given every day, and to-day 
the calomel was again tried, but it is a question whether 
the stomach has retained any of the soda or calomel. The 
bowels have not been moved since December 2, notwith- 
standing the numerous enemata that have been given. 
Every day two or three high rectal enemata of one pint or 
more of normal salt solution or bicarbonate of soda solu- 
tion have been given. These solutions for the most part 
have been absorbed. The water and salts absorbed in 
this way have kept the kidneys more active, prevented 
great loss of weight, and otherwise favorably influenced 
the course of the attack. The urine examined on the 6th 
contained acetone, diacetic and oxybutyric acids, and 
the vomited matter contained free hydrochloric acid. 

December 7. Vomiting ceased to-day and stomach re- 
tained some water and a little malted milk. 



29O NEUROTIC DISORDERS OF CHILDHOOD 

December 8. Bowels moved to-day following a dose 
of Epsom salts. 

From this time on convalescence was rapid. Within 
one week the patient had gained the four pounds she had 
lost during the attack, and was in every way as well as 
before the attack. As soon as convalescence was es- 
tablished she resumed in every detail the interval treat- 
ment above described. 

January 24. Is better than she has been for years, 
weight 60 pounds, and looks like a well child. Treat- 
ment continued. Massage, diet, outdoor life, and medi- 
cation. 

March 24. Has remained well and has continued to 
gain in weight; now appears to be a perfectly normal 
child. 

May 1. Continues to gain in weight, health, and 
strength, and has, up to the present time, had no further 
attacks. 

Case XL Male, aged 7. Family History. — Father and 
one uncle had neuritis ; father has " bilious headaches " 
characterized by severe hemicrania and accompanied by 
nausea and vomiting. Mother has a gouty and " rheu- 
matic " family history. 

Personal history obtained from Dr. Collins H. John- 
ston, Grand Rapids, Michigan. This boy has always had 
more or less trouble with his digestive organs, suffering 
at intervals with constipation, coated tongue, and lack of 
appetite. He has had at intervals nocturnal incontinence 
of urine, and has also suffered from habit-spasm. The 
attacks of habit-spasm consisted in twitching of the mus- 
cles of the face, blinking of the eyelids, and raising the 



A CLINICAL STUDY OF KINDRED CASES 29 1 

eyebrows, all of which were made worse when attention 
was called to them. Associated with these attacks there 
was considerable nervous irritability and disturbance of 
articulation. Neither the incontinence of urine nor the 
habit-spasm has been continuous; they would disappear 
when the boy's general health was improved, and would 
return when his nutrition was markedly impaired. 

He has suffered from attacks of naso-pharyngeal 
catarrh throughout his life. When he was five years of 
age he was operated on for enlarged adenoids, and two 
months later he had a severe attack of influenza, marked 
by severe catarrhal inflammation of the throat and nose, 
and complicated by a suppurative otitis media. During 
this attack he had gastro-enteric symptoms and severe 
vomiting. Since infancy he has had occasional attacks 
of vomiting thought to be due to indigestion. During his 
fourth year he had three of these attacks, about three 
months apart, each lasting two or three days, and one 
year later he had another vomiting attack lasting four 
days ; following this the next vomiting occurred in Febru- 
ary, 1903, with the influenza attack above noted. In 
September, 1903, he had another attack, lasting four 
days, preceded as were nearly all of his attacks by acute 
catarrh of the nose and throat and considerable fever. 
This attack was followed by another, one month later 
(October, 1903), lasting four days. In December, 1903, 
occurred an attack of vomiting, which nearly terminated 
his life. This attack began with nasal congestion, list- 
lessness, loss of appetite, and constipation, followed a 
few hours later by nausea, and twenty-four hours later 
by vomiting, and for ten days the nausea was continuous 



292 NEUROTIC DISORDERS OF CHILDHOOD 

and the stomach irritability was so great that not a par- 
ticle of food or water was retained. During this time 
every effort was made to control the vomiting; food was 
given at intervals and again withheld; thirst was ex- 
cessive. The highest temperature reached, 100.8, oc- 
curred in the beginning of the attack. After the sixth day 
the patient seemed so dangerously ill that nutrient 
enemata were given. They were followed, however, by 
an irritation of the large intestine, which prevented the 
giving of food and medicines in this way. The patient's 
condition was now, on the eighth day of the attack, very 
alarming, the nausea was continuous, and the vomiting 
occurred at intervals without apparent exciting cause; 
pulse 140, feeble and intermittent, respiration sighing, 
restlessness extreme, abdominal distress, extremities cold, 
finger nails blue, eyes sunken, skin cyanotic, and emaci- 
ation and prostration extreme. Dr. Johnston now gave 
hypodermically one-twelfth grain of morphine, combined 
with atropin and strychnine, and subcutaneously three 
ounces of salt solution. The boy improved at once un- 
der this treatment. The morphine had to be repeated a 
number of times, but from this time on the stomach be- 
came less irritable and he began to take and retain liquid 
foods. Convalescence was slow but uninterrupted. He 
was confined to his bed for one month, and was then 
taken to Florida in a private car. In Florida he slowly 
regained his usual health, and had another attack on 
April 11. This attack was very severe, lasted six days, 
and was finally controlled by morphine. His convales- 
cence from this attack was slow. As soon as he was 
well enough he was taken to his home in Michigan, where 



A CLINICAL STUDY OF KINDRED CASES 293 

he had another severe attack about the first of August, 
1904. 

August 25 I saw this patient for the first time, and al- 
though it had been three weeks since his last attack he 
was very nervous, emotional, anaemic, emaciated, feeble, 
and confined to his bed most of the time. I advised the 
following treatment: Light general massage every day, 
out-of-door life with as much exercise as the boy's 
strength would permit, and a diet and medication exactly 
similar to that prescribed in Case X, above reported. 

October 20, nearly two months later, I saw this boy 
for the second time. The treatment prescribed had been 
continued; the improvement was very remarkable. He 
was better than he had been for years. He had gained 
eight pounds in weight, and was able to indulge in all 
kinds of outdoor play with boys of his age. He had lost 
much of his nervous irritability, but was still quite emo- 
tional. He had a voracious appetite, which had to be 
somewhat restrained. His digestion was good; he was 
eating largely of the full diet prescribed two months be- 
fore. Treatment continued and outdoor life insisted upon. 

January 1, 1905. The father writes me that the boy 
is now strong and well. 

June 6. More than nine months have passed since the 
beginning of the treatment, and during this time the 
patient has had no attack of vomiting. He has gained 
gradually in health, strength and weight, so that at the 
present time he weighs fourteen pounds more than he did 
nine months ago, and has apparently the strength and en- 
durance of the average child, but he is perhaps abnor- 
mally nervous and emotional. 



294 NEUROTIC DISORDERS OF CHILDHOOD 

From January 15 to the present time the patient has 
taken, early each morning, a small portion of " Siphon 
C" (page 208), just sufficient to produce an evacu- 
ation of the bowels during the forenoon, and this has 
been accompanied at times by tonics containing arsenic 
or a diastase. The prescription containing benzoate and 
salicylate of soda (page 233) has, during this period, 
been used on two occasions for a week or ten days at a 
time, and these occasions were determined by the pres- 
ence of certain symptoms which indicated that an at- 
tack of recurrent vomiting might be impending. At 
such times bicarbonate of soda, grains five, and calomel, 
grain one-quarter, was given every half-hour for eight 
doses, and followed for a week or ten days by the ben- 
zoate and salicylate of soda prescription above referred 
to. Under this treatment the prodromal symptoms 
quickly disappeared, and the patient continued his practi- 
cally uninterrupted convalescence and return to health 
and strength. 

Cases IX, X, and XI make a very instructive group, 
and their study clearly indicates the close relationship 
which exists between recurrent coryza and recurrent 
vomiting. 

Case IX was one of recurrent coryza, these attacks at 
times being complicated by or alternated with recurrent 
vomiting. There can be little question that in this 
case these two syndromes were produced by the same 
auto-toxins acting upon different parts of the vasomotor 
nervous system, the primary point of attack determin- 
ing whether the syndrome of recurrent vomiting or of 
recurrent coryza was to predominate in the attack. 



A CLINICAL STUDY OF KINDRED CASES 295 

Case X illustrates also the close connection between 
these syndromes. In this patient, attacks of recurrent 
vomiting were almost always preceded by coryza, and 
sometimes by whistling bronchitis. The association of 
these symptoms with those of recurrent vomiting was so 
close that in nearly all of her earlier attacks she was 
treated in the beginning for " cold in the head and bron- 
chitis/' and the medicines used in the treatment of these 
symptoms were thought to bring on the secondary "gas- 
tritis/' which continued for days ofter the " cold " had 
disappeared. It later became evident to her parents that 
the coryza and whistling bronchitis zvere a part of the at- 
tack. This child has had eighteen to twenty attacks of 
recurrent vomiting, and in the great majority of them 
the syndromes of recurrent coryza, whistling bronchitis, 
and recurrent vomiting have been blended. This is not 
a coincidence, and can only be explained on the theory 
that the auto-toxins produce this combination of symp- 
toms by their action on different parts of the vasomotor 
nervous system. 

Case XI shows this same association of symptoms. In 
this boy, who has suffered from a large number of very 
severe attacks of recurrent vomiting, nearly all of tliese 
attacks have been preceded or accompanied by a more or 
less marked coryza, and at times by an irritation of the 
throat and bronchial mucous membranes. 

These three cases, therefore, establish the fact that the 
syndromes of recurrent vomiting and of recurrent coryza 
are not uncommonly blended, and may be produced by 
the same auto-toxins. 

A further interest attaches to Cases X and XI, in that 



296 NEUROTIC DISORDERS OF CHILDHOOD 

they zv ere very severe cases of recurrent vomiting that, 
from the beginning, yielded promptly to treatment. 

Case XII. Male, aged 6. Mother has migraine and 
grandmother on mother's side is gouty and intensely neu- 
rotic. Father is of a " bilious temperament " and has 
bilious headaches. Sister, three years of age, has had 
two attacks of recurrent vomiting. 

Patient, when two years of age, had his first attack of 
recurrent vomiting, and since then has had two attacks 
each year up to one year ago, when he was put under 
treatment. The attacks from which this boy suffered 
were typical and moderately severe, lasting from four to 
six days. They, for a long time, were attributed to er- 
rors in diet, but their similarity and regular recurrence 
led the mother to the belief that they were constitutional 
and responsible for the marked nervous irritability from 
which the child constantly suffered. This case is re- 
ported for the purpose of calling attention to the interval 
condition of the child. Notwithstanding the fact that 
these attacks occurred but twice a year, he was in a de- 
plorably nervous condition all the time. When awake 
he was never quiet. This nervous restlessness was very 
much exaggerated at times, and these exacerbations of 
restlessness were associated with a loss of appetite, 
coated tongue, canker sores in the mouth, and a sallow- 
ness of complexion, all of which symptoms his mother 
grouped under the term "biliousness." Under calomel 
these symptoms would disappear. These " bilious at- 
tacks " occurred every three or four weeks, and twice a 
year they were the prodromes of an attack of recurrent 
vomiting. 



A CLINICAL STUDY OF KINDRED CASES 29/ 

This child was never well, and his constant restlessness, 
which showed itself in his arms, legs, and head, gave the 
impression that he was below normal in mental develop- 
ment. I saw the patient for the first time in October, 
1903, and put him under the treatment outlined in Case 
X, without the massage. More than sixteen months 
have now elapsed since he was put under treatment, and 
he has not had an attack in this time. His "bilious at- 
tacks/' his general restlessness, and nervous irritability 
have almost disappeared, and he is now almost if not 
quite physically and mentally a normal child. 

Case XIII. Female, aged 12. Family History. — An 
own cousin of her mother, Case VI, had recurrent vomit- 
ing, migraine, and epilepsy. Her father is gouty and suf- 
fers from gall stone attacks. 

Personal History. — When six years of age she almost 
lost her life in a very severe attack of scarlet fever, which 
was followed by a middle ear infection, and when seven 
years of age she was operated for mastoid disease. 
These illnesses left her weak, anaemic and nervous. 
When six years of age she had her first attack of recur- 
rent vomiting. These attacks recurred at intervals until 
she was ten years of age, at which time I saw her and 
put her under treatment. From this time up to six 
months ago she had no attack of recurrent vomiting and 
she had steadily improved until her general appearance 
indicated fairly good health, but she was still much more 
nervous and emotional than the average child. 

About six months ago, April, 1904, she contracted 
measles, which was complicated by one of the most 
violent attacks of recurrent vomiting it has ever been 



298 NEUROTIC DISORDERS OF CHILDHOOD 

my misfortune to see. This attack in the beginning 
was thought to be an uncomplicated case of severe recur- 
rent vomiting. I was led to this opinion because this 
attack began very like her other attacks. The nausea 
was constant, the vomiting very severe and exhausting, 
and no water or medicines were retained by either the 
stomach or rectum; the large intestine seemed almost as 
intolerant as the stomach. The symptoms increased in 
severity, and on the fifth day of the attack a well-de- 
fined measles rash appeared, and I then realized that the 
catarrhal irritation of the bronchial, nasal, and conjunc- 
tival mucous membranes, which had been present for two 
or three days, were symptoms of measles. The measles 
rash was typical and remained out for three days, dis- 
appearing on the eighth day of the attack, but during 
all this time the nausea and vomiting continued and no 
food or water was retained either by the stomach or large 
intestine. The prostration was now extreme, the pulse 
was feeble and rapid, the temperature 96 F., and the child 
was delirious. At this time I gave one-eighth grain of 
morphine hypodermically, and threw under the two 
breasts one pint of sterile physiological salt solution. The 
effect of this medication was magical; the nausea and 
vomiting stopped at once and the child slept for three 
hours. From this time on the stomach retained water 
and liquid foods in small quantities, but the morphine had 
to be given at intervals of six or eight hours for the next 
two days to prevent a return of the vomiting. After 
this her convalescence was rapid, and she is now, twelve 
months later, in better condition than she has been for 
years. 



A CLINICAL STUDY OF KINDRED CASES 299 

The above case is one of extreme interest, and is here 
reported because it is the only instance I have ever seen 
in which an attack of measles, or other acute infection, 
precipitated an attack of recurrent vomiting in a child 
which has been subject to these attacks. It is an interest- 
ing question in this case whether the measles poison, by 
its action on the nerve centers, was the cause of the 
vomiting, or whether this poison was assisted by a com- 
plicating auto-intoxication, viz., the same that had pro- 
duced the previous attacks. I rather incline to the latter 
opinion. 

Case XIV. Female, aged 5. Mother comes from a 
gouty family, and has for many years suffered from mi- 
graine, and for the last two years had nervous prostra- 
tion. Patient is the youngest of four children; all the 
others are strong and well. 

July, 1903. Saw this patient for the first time in a 
well-marked attack of recurrent vomiting, which lasted 
four days. On the third day of the vomiting the som- 
nolence which had been present throughout the attack be- 
came more marked, and the mother, who had observed 
the child in many attacks, predicted that she would be 
better when she awoke from this deep sleep, as she knew 
by experience that a prolonged and profound sleep 
preceded the beginning of convalescence. The high 
enemata of bicarbonate of soda solution which were given 
in this case may have had some influence in shortening 
this attack. 

One week later, when this patient had recovered from 
the attack, I found her to be very nervous, precocious, and 
attractive. I then prescribed the same treatment above 



300 NEUROTIC DISORDERS OF CHILDHOOD 

described in Case X, and since that time, now eighteen 
months, she has had no attacks of recurrent vomiting, 
and her general condition has greatly improved. 

Case XV. Female, aged, 3. A sister of Case XII. 
Had a severe attack of vomiting one year ago. In this 
attack the vomiting lasted three days, and during this 
time everything taken into the stomach was rejected; the 
stomach then suddenly became tolerant, and convalescence 
was rapid. 

During the past year this child has, on the whole, been 
well. She has had, however, a number of " bilious 
spells," in which for a few days she would lose her ap- 
petite, become nervous and irritable, have a coated 
tongue and bad breath, and the constipation, which is 
habitual with her, would at these times become very ob- 
stinate. These attacks would yield to calomel, and the 
child would in a few days be as well as usual. 

About four weeks ago the mother called my attention 
to the child because of certain nervous symptoms that had 
developed, which were associated with the most obstinate 
constipation; she was nervous and irritable during the 
day, and had had attacks of night-terrors for the last five 
nights. The constipation yielded only to strong doses of 
cathartic medication. A few days later a typical attack 
of recurrent vomiting began. The vomiting lasted four 
days, and was followed by a rapid convalescence. The 
urine contained acetone and diacetic acid. This patient 
slept almost continuously for the last forty-eight hours of 
the attack. During this time she could be readily aroused, 
but would quickly fall asleep again. When she was 
awakened from this profound sleep she was nauseated, 



A CLINICAL STUDY OF KINDRED CASES 301 

and would vomit when anything was taken on the 
stomach. On the morning of the fifth day the drowsi- 
ness passed away, the stomach lost its irritability, and 
convalescence began. 

Cases XIV and XV are reported for the purpose of 
again calling attention to the narcotism (noted in Case 
X) which sometimes marks the close of attacks of re- 
current vomiting, just as it does of attacks of migraine. 



CHAPTER XX 

CHOREA 

Synonyms. — St. Vitus' dance, St. Anthony's dance, 
chorea minor, Sydenham's chorea. 

Definition. — Chorea is a syndrome characterized by 
involuntary, inconstant, incoordinate, and jerky muscu- 
lar contractions involving a part or all of the voluntary 
muscles, and occurring only when the patient is awake. 

MORBID ANATOMY AND PATHOLOGY 

In the present state of our knowledge it seems probable 
that chorea may be produced by a large number of organic 
lesions of the nervous system, and by the bacteria or 
toxins of certain acute infections, as well as by nutri- 
tional changes and functional derangements of the 
cerebral cortex. The widely varying pathological condi- 
tions which may be responsible for chorea make it expe- 
dient that this condition should be described as a syn- 
drome rather than as a definite disease. 

Organic Chorea. — If the large number of organic 
lesions of the nervous system which have been found to 
be associated with this disease are accepted as patho- 
logical factors of this syndrome, then it may be caused 
by inflammatory and degenerative lesions of the optic 
thalmus, corpus striatum, lenticular nucleus, and cerebral 
cortex, as well as by other diseases of the central nervous 
system. 

302 



CHOREA 303 

Meynert and Elischer found hyaline degeneration in the 
nerve cells of the basal ganglia and cerebral hemorrhage 
and capillary emboli in the brain cortex. Dana, in a fatal 
case of chorea that had lasted for more than twelve years, 
and that apparently conformed to the Sydenham type, 
found a chronic lepto-meningitis of the cerebrum, 
meningitis of the upper part of the spinal cord, hyaline 
bodies in the brain cortex, and degenerative changes in 
the arterial walls, with dilated lymph spaces in the inter- 
nal capsule, corpus striatum, and optic thalmus. Accom- 
panying these changes were noted degeneration of the 
nuclei of nerve cells. A number of authors have reported 
congestions, hemorrhages, embolism, and softening of the 
brain tissue. These lesions are more commonly found in 
the lenticular nucleus, optic thalmus, and motor portions 
of the cerebral cortex. In a number of cases minute hya- 
line bodies have been found in the lenticular nucleus. 

Among other lesions of the cerebrum that have been 
noted, on autopsy, as being associated with chorea may be 
mentioned cysts, tubercules, trauma from depressed bone, 
cicatrices from all hemorrhages, and all brain injuries 
producing hemiplegia. 

If in the cases reported the above injuries have been 
responsible for the syndrome of chorea, it is very evident 
that it may be produced by a large number of widely 
varying pathological conditions. Organic chorea there- 
fore has no definite pathology, and it is questionable 
whether these cases, which are for the most part chronic 
and incurable, should be included in a description of 
Syndenham's chorea. These cases, however, except for 
their chronicity and incurability, present the same clinical 



304 NEUROTIC DISORDERS OF CHILDHOOD 

picture, and have therefore by all writers been described 
with the toxic and idiopathic cases. 

The embolic theory, which holds that chorea is com- 
monly produced by capillary emboli washed from the 
vegetations which occur in endocarditis into the capil- 
laries of the brain, is a theory not in keeping with patho- 
logical findings. It therefore deserves no further con- 
sideration. 

Toxic Chorea, or chorea due to acute bacterial tox- 
aemia, has within recent years attracted a great deal of 
attention, and there can be little question that at 
least a considerable proportion of the cases of chorea 
belong to this type. This type of chorea, however, does 
not include those cases which are produced by inflamma- 
tions of the brain or its membranes, even though bac- 
terial findings may be present. They have been classified 
above among organic choreas. 

The toxic choreas include only those cases produced 
by the direct action of bacterial or other toxins on the 
nervous system, which slowly disappear when these tox- 
ins have been eliminated. The cases of chorea which 
occur during or immediately after the acute infections, 
including rheumatism, probably belong to this class. 

Cesares-Demel, by injection of pathogenic micro- 
organisms and their toxins under the dura mater, has 
succeeded in producing a symptom group similar to 
chorea. 

Idiopathic Chorea. — Organic lesions of the brain 
and acute and chronic bacterial toxaemias are responsi- 
ble, perhaps, for more than half the cases of chorea, but 
a large minority of the cases of ordinary chorea are, from 



CHOREA 305 

a pathological standpoint, yet to be accounted for. These 
are the great group of so-called idiopathic choreas that 
are believed to be due to nutritional and functional dis- 
turbances of the brain. 

GENERAL ETIOLOGY 

Predisposing Causes. — Age. — Chorea begins as a rule 
between the ages of six and fifteen, but the largest num- 
ber of cases occur between nine and thirteen. It is rare 
to see the disease in children under three and a half 
years of age. Cases, however, have been reported as 
occurring in infancy, and old age is not exempt from this 
disease. 

Heredity. — A neurotic family history •is very common, 
and in not a few cases there is a direct family history 
of chorea. It is not uncommon to find two or more 
cases of chorea in the same family at different times, so 
that imitation could play no role in precipitating the 
attacks. Chorea, epilepsy, and migraine not uncommonly 
occur in the same families, and all of these neuroses may 
occur in the same patient at different periods of life. 
A family history of gout arthritism and migraine is 
fairly common in these cases. 

Sex. — Chorea occurs in females three times as com- 
monly as it does in males. This proportion is given by 
Gowers, Sinkler, and other writers. 

Season. — All writers agree that chorea occurs most 
frequently in the spring; it, however, may occur at any 
season of the year. Morris J. Lewis examined 1383 
cases of chorea with reference to the beginnings of the 
attacks, and found that of these 106 occurred in January, 



306 NEUROTIC DISORDERS OF CHILDHOOD 

ioi in February, 172 in March, 159 in April, 160 in May, 
150 in June, 126 in July, 106 in August, 76 in September, 
74 in October, 54 in November, 99 in December. 

The frequency with which chorea occurs during the 
months of March, April, May, and June has been vari- 
ously explained by different writers. Some believe that 
the prevalence of rheumatism and other acute infections 
during these months is the explanation; others that the 
strain of school life and school examinations is the cause. 
In a former publication 1 I expressed the belief that the 
prevalence of chronic anaemia, from a multitude of 
causes, is in part responsible for the frequency of chorea 
at this season. 

Race. — It is very uncommon in the negro race, but is 
very prevalent, according to Dana, among the Germans, 
Hebrews, and Portuguese of New York. Other writers 
have noted its prevalence among the Jews. Sinkler 
says that in Philadelphia it is " more common in children 
of American parentage than in foreigners." On the 
whole, however, it is probable that race in and of itself 
has little influence. 

Climate has little influence so far as heat and cold are 
concerned. It may, however, be stated that a climate 
which is unfavorable for outdoor life will predispose to 
chorea and other neuroses. 

Social Station. — Chorea is alike prevalent in all sta- 
tions of life. Chronic anaemia and malnutrition, as etio- 
logical factors of chorea among the poor, are offset by 
the arthritic diathesis and nervous strain so common 
among the children of the rich. 

1 Medical Ne%v$, 



CHOREA 307 

Direct Causes. — Rheumatism. — There is perhaps no 
fact better established in medicine than that the poison 
of rheumatism is responsible for about 25 per cent, of 
all cases of chorea. The relationship between chorea and 
rheumatism has been recognized for many years, but 
even at the present time there are great differences of 
opinion as to the importance of the rheumatism poison 
as a factor in producing chorea. Many writers assert 
that from 50 to 60 per cent, of all cases are due to this 
cause, and others hold that as few as 15 or 20 per cent, 
of these cases are rheumatic in origin. Osier found in 
554 cases, 88, or 13.8 per cent., were due to rheumatism; 
he also found that 15.5 per cent, of these cases had a 
rheumatic family history. F. M. Crandall analyzed in, 
and found a definite history of rheumatism in 63, or 
nearly 60 per cent. Holt believes that evidences of 
rheumatism may be found in 50 or 60 per cent, of all 
cases. Sinkler examined 927 cases and found that " there 
was a history of rheumatism, acute or chronic, in 187 
cases, or 20.1 per cent; and in addition to this there 
were 38 cases in which the children were said to have 
"growing pains"; in 79 cases, or 8.5 per cent., there 
was a distinct history of acute articular rheumatism ; the 
intervals between the rheumatism and the attack of 
chorea varied from six years to immediately preceding; 
in 38 cases the attack of rheumatism had occurred within 
one year of the chorea; in 8 cases acute rheumatism im- 
mediately preceded the chorea, and in 7 the two affections 
were coincident." 

Starr analyzed 2476 cases and found evidences of 
rheumatism in 26 per cent. The following table is taken 



303 



NEUROTIC DISORDERS OF CHILDHOOD 



from " The American Text-Book of Diseases of Chil- 
dren ": 

Table I.— Showing the Relationship of Chorea, Rheumatism, and 
Endocarditis (Starr). 



Author. 


« . 

us 


1 

s 

a 

A 

ft 


Cardiac 


Reference. 


Groendal. .. 


52 
121 

267 

30 

I96 

80 

20 

80 

80 

84 

439 

IOO 

70 

ISO 

279 

448 


37 
11 

48 

14 

134 

5 

3 

37 

36 

62 

116 

24 

8 

7 

37 

83 


Majority 
15 

3 l 

""5 

8 

20 
45 

'141 

40 
12 
8 
82 
83 


Wien. Med. Woch., Mar. 26, 1891 

Berl. klin. Woch., July 14, 1890 

Arch. klin. Med., 1886 

Deut. Med. Woch., July, 1888 

La Med. Moderne, October, 1891 

Rev. Mens, des Mai. de l'Enf., June, 1890 

Lancet, October 31, 1891 

Lancet, January 12, 1889 

Lancet, January 12, 1889 

Lancet, May 4, 1889 

British Med. Journ., Feb. 28, 1857 

Dis. Nerv. System, Vol. II., p. 550 

Keatirig's Cyclo. Child. Dis. Vol. IV., p. 843 

Arch, of Pediatrics, April, 1888 

Pepper's System of Med., Vol. IV., p. 44 


Meyer . . , 


Koch 


Peiper 


sec 1 . :.:.:::; 


Leroux 


Dale 


Herringham 

Garrod 


Cheadle 


Brit. Col.Invt.Com 
Gowers 


Sachs 


Dana 


Sinkler 


Starr 








2476 


662 

26 per 
cent. 


502 + 





The variation in percentages presented by different 
writers depends upon the individual writer's idea of 
what constitutes rheumatism. Almost all writers at the 
present time agree that rheumatism is an acute affection. 
The term, however, is used very loosely. By some writers 
it is spoken of as a definite disease, by others as a syn- 
drome. If by rheumatism we mean broadly a symptom 
group characterized by fever, arthritis, and, commonly, 
endocarditis, then the term is a very broad one, and 
covers the rheumatism syndrome, not only of true rheu- 
matism (acute inflammatory rheumatism), whose specific 
cause is unknown, but also the same syndrome when it 
accompanies or follows such acute or chronic infections 



CHOREA 3O9 

as tonsilitis, septicaemia, tuberculosis, scarlatina, influ- 
enza, diphtheria, typhoid fever, measles, gonorrhoea, and 
syphilis. The syndrome of rheumatism is very com- 
monly produced by an infection which enters the body 
through the tonsils, and is often preceded by a quinsy 
or an ulcerative tonsilitis. F. A. Packard has called 
special attention to the relationship which exists between 
tonsilitis, endocarditis, and rheumatism. 

The syndrome of rheumatism being produced by such 
a large number of micro-organisms cannot in any direct 
sense be hereditary. Individuals, however, may inherit 
arthritism or a susceptibility to inflammations of serous 
membranes. This hereditary taint is in many instances 
related to the gouty diathesis. Such individuals by 
reason of this inheritance would be more susceptible to 
the syndrome of rheumatism. That is to say, they would 
be more likely to have arthritis, endocarditis, and their 
accompanying symptoms and sequelae than those indi- 
viduals who had not inherited this diathesis. 

Patients having once suffered from the syndrome of 
rheumatism would be predisposed to second attacks by 
reason of the fact that the micro-organisms which pro- 
duced the first attack may remain in a latent form in or 
near the joints, so that exposure to cold, dampness, and 
various other exciting causes might precipitate an attack. 
Chorea may be a part of the rheumatic syndrome, what- 
ever its origin. This is especially true when this syn- 
drome includes both arthritis and endocarditis. All of 
the acute infections mentioned above may also produce 
chorea without the appearance of the rheumatic syn- 
drome. 



310 NEUROTIC DISORDERS OF CHILDHOOD 

If the term rheumatism is used, therefore, to include 
all cases that present the rheumatic syndrome, however 
ill defined it may be and whatever may be its origin, then 
it is more than probable that rheumatism is associated 
with 50 or 60 per cent, of all cases of chorea. If, how- 
ever, we eliminate the vague cases of " growing pains " 
and all those produced by acute infections other than 
true rheumatism, then the percentage will fall to between 
20 and 25 per cent. 

True rheumatism is a definite and distinct disease 
characterized by fever, arthritis, acid perspirations, and, 
commonly, endocarditis, and yielding, in a degree, to 
the alkaline and salicylic acid treatment. The difficulty 
has been, and still exists, that this disease is probably 
produced by an unknown infectious agent, and therefore 
cannot be differentiated by bacteriological or patho- 
logical findings from the rheumatic syndrome which 
is produced by a large number of other infectious 
agents. 

The clinical picture, however, of rheumatism is clearly 
enough defined in most cases to make the clinician fairly 
sure of his diagnosis. Confusion, however, will continue 
to exist so long as the exact pathology of rheumatism 
is unknown, and so long as the term is loosely used in 
describing a syndrome instead of a disease. 

It is important, however, in studying the relationship 
which exists between rheumatism and chorea, that we 
should differentiate those cases that are produced by 
true rheumatism from those cases which are associated 
with the syndrome of rheumatism produced by other 
forms of infection. Rational therapeutics, in many of 



CHOREA 3 1 1 

these cases, will depend upon our ability to make this 
differentiation. 

Heart Disease. — Chorea is very commonly associated 
with some disease of the heart ; this may be an endocar- 
ditis, pericarditis, or merely a weakening and irritability 
of the cardiac muscles. Endocarditis may manifest 
itself in a systolic murmur, soft in character and com- 
monly heard at the apex, and not infrequently heard at 
the base. Aortic murmurs are rare, but are occasionally 
observed. In some cases it is difficult to say whether the 
cardiac murmur is due to a mild endocarditis or to a 
malnourished and irritable heart muscle, with possibly a 
low grade of myocarditis. Cardiac sounds, however, 
associated with chorea, are to be classed as organic until 
it can be definitely proven that they are not so. Irregu- 
larity in the force and rhythm of the heart's action may 
be found without any evidence of endo- or pericarditis. 
These cases are, as a rule, very anaemic and malnour- 
ished. Pericarditis may produce well-marked friction 
sounds followed by an increased dullness in the cardiac 
area. 

The association of heart disease and chorea is graphi- 
cally shown in Starr's table, page 308. In 2476 cases, 
25 per cent, had heart disease, and the collective investi- 
gation of the British Medical Association, which is in- 
cluded in this table, found heart disease in 32 per cent, of 
439 cases of chorea. 

All writers are agreed that there is a close relationship 
between arthritis, endocarditis, and chorea, about 25 per 
cent, of all choreic cases presenting at some time in their 
history well-marked symptoms of arthritis and about 25 



312 NEUROTIC DISORDERS OF CHILDHOOD 

per cent, showing previous disease of the heart. Writers, 
however, are not agreed as to the exact relationship 
which exists between these three conditions, some 
believing that the endocarditis, rather than the arthritis, 
is the important factor in producing the chorea, and 
others believing, with Cheadle, that the arthritis, endo- 
carditis, and chorea are but different manifestations of 
the rheumatic poison, and that the syndromes of arthritis 
and endocarditis have nothing to do directly with the 
production of chorea. The symptom group which the 
rheumatic poison may produce depends altogether upon 
whether it attacks the joints, the heart, or the nervous 
system, and the order of appearance of these symptom 
groups when they occur in the same individual will de- 
pend upon whether the nervous system, the heart, or the 
joints is the point of first attack. In some instances 
the chorea precedes both the rheumatism and the endo- 
carditis. In others it may follow either one or both of 
these symptom groups. My own opinion accords with 
these views, that rheumatism is a specific poison which 
may produce chorea by its action on the nervous system, 
and endo-, peri-, and myocarditis by its action on the heart, 
and arthritis by its action on the joints. One or more of 
these syndromes may occur in the same individual, and 
the order of their sequence is not important. 

The association of endocarditis with chorea in other 
acute infections, such as streptococcic infections of the 
tonsils, scarlet fever, etc., does not prove that the endo- 
carditis is etiologically related to the chorea. The chorea 
here may also be an expression of the action of the 
specific poison on the nervous centers. The common 



CHOREA 3 J 3 

association, however, of endocarditis and chorea pro- 
duced by a number of the acute infections has suggested 
to medical writers the possibility of the endocarditis being 
a factor in the production of chorea. The theory of 
the embolic origin of chorea, which has now been dis- 
carded, had its origin in this association. At the present 
time, however, some medical writers believe that the 
feebleness and irregularity of the capillary circulation 
of the brain which may result from heart disease may be 
a factor in producing chorea. 

Chronic Lymph Node Tuberculosis, which is one of 
the most potent factors in producing anaemia and 
malnutrition in childhood, is one of the most important 
etiological factors of chorea. I came to this conclusion 
from careful studies in the children's clinic of the Medical 
College of Ohio extending over a period of ten years. 

The family histories in such records are necessarily 
incomplete, and " negative " or " good " is sometimes 
written when a family history of tuberculosis exists. 
The long-continued association, in the medical mind, of 
chorea, rheumatism, and endocarditis makes it altogether 
probable that the histories in public clinics record every 
semblance of these diseases, and the fact that tuberculous 
malnutrition and chorea have never been closely asso- 
ciated in the medical mind makes it also very probable 
that these histories do not record all the cases of tuber- 
culosis. I have elsewhere called attention to the fact 
that the diagnosis of tubercular malnutrition is very com- 
monly overlooked, and one is justified in making a pro- 
visional diagnosis of concealed tuberculosis in every well- 
marked chronic malnutrition occurring without apparent 



314 NEUROTIC DISORDERS OF CHILDHOOD 

cause in young children in whom there is a family his- 
tory of tuberculosis, or exposure to the tuberculous con- 
tagion. 

When we investigate our cases of chorea as carefully 
for evidences of concealed tuberculosis as we now do 
for vague signs of rheumatism and heart disease, we will 
find that at least 25 per cent, of the cases of chorea 
occurring in public clinics have tuberculosis in an active 
enough form to produce profound anaemia and malnu- 
trition. An examination of 91 cases of chorea from my 
clinical records includes 28 tuberculous cases. In these 
cases cod-liver oil and iron, with good food and open- 
air treatment, gave the best results. 

Chronic Malaria and other diseases which produce 
profound anaemia and chronic malnutrition may be etio- 
logically related to chorea. In Chapters VI and VII 
I have called attention to the blood changes which are 
responsible for the profound anaemias and malnutritions 
which diseases of this character produce, and to the 
potency of these factors in producing an irritable and un- 
stable condition of nerve centers, thus predisposing to 
functional diseases of the nervous system, such as 
chorea. 

Exciting Causes. — Fright, which by nearly all writers 
is classed as one of the most important exciting causes of 
chorea, is responsible for the onset of the attack in about 
20 per cent, of all cases. The fright, however, in these 
cases is made potent only by the presence of other very 
important etiological factors, such as profound malnu- 
trition, heart diseases, or inherited neurotic tendencies. 
In studying the etiology of functional nervous diseases 



CHOREA 3 J 5 

such as chorea, it is important to keep in mind the tripod 
of etiological factors upon which these diseases rest. 
First, the predisposing factors, such as heredity, age, 
sex, and social condition. Second, the blood state, such 
as may be produced by acute and chronic infections and 
chronic malnutritions of all kinds; and, lastly, the excit- 
ing causes which, in individuals made susceptible by the 
two preceding factors, act in touching off the particular 
nervous syndrome. Fright acts in this manner in pro- 
ducing chorea in susceptible individuals. 

Among other exciting causes which act in this way 
may be mentioned gastro-intestinal diseases, worms, de- 
layed menstruation, eye-strain, diseases of the nose and 
pharynx, phimosis, masturbation, pregnancy, and imi- 
tation. 

Duration. — The average duration is about ten weeks. 
Mild cases may get well in two or three weeks, and severe 
ones may continue for months. The attacks that continue 
longer than this are, as a rule, very severe throughout 
their course and are dependent upon grave etiological 
factors. Cases with severe cardiac lesions and grave 
nutritional disturbances may continue for six months or 
more, and cases in which the chorea continues for years 
are usually dependent upon organic disease of the nerv- 
ous system. Such chronic cases, however, are rare even 
in organic chorea. 

Recurrence. — Children who have had chorea are to 
be kept under observation for a number of years, in order 
to prevent a recurrence. Attacks may recur at the same 
time of the year, until the etiological factors which pro- 
duced the first attack have been removed or until age 



3l6 NEUROTIC DISORDERS OF CHILDHOOD 

confers immunity. Recurrences are not common after 
fifteen. During the period of susceptibility to chorea, 
subsequent attacks may be produced by any of the above- 
named exciting causes. 

Second and third attacks occur in about one-third of 
all cases, and girls by reason of their predisposition to 
neurotic diseases are more apt to have recurrences. Cases 
suffering from profound nutritional disturbances which 
do not yield readily to treatment, and children suffering 
from chronic diseases of the nose and throat predispos- 
ing them to acute infections, and those suffering from 
severe organic disease of the heart, are more likely to 
have subsequent attacks, and these attacks are, as a rule, 
similar in their course and severity to the first attack. 

PROGNOSIS 

The prognosis is good. When death occurs it is 
due to the organic disease of which the chorea is a 
symptom, and in the few cases that become chronic, 
while the organic disease is not severe enough to pro- 
duce death, it is irremediable and severe enough to 
continue indefinitely the paroxysm of chorea. 

Urine. — The urine in these cases does not assist in the 
diagnosis or prognosis. It very commonly is of high 
specific gravity, and the phosphates and urates are 
increased. 

SYMPTOMS 

Before the characteristic symptoms of chorea develop, 
the child, as a rule, is anaemic, nervous, and irritable. At 
school the teacher may observe his inability to sit still 
and a clumsiness in the handling of objects. The drop- 



CHOREA 317 

ping of pencils, books, and other objects brings reproof, 
under which the child's restlessness increases. Very soon 
twitchings of the muscles of the shoulder, face, or hand 
suggest the fact that the child is ill, and a physician is 
consulted. 

In the early history of mild attacks the child may be 
able to partly control these irregular movements, but 
muscular spasm may be detected by directing the child 
to perform very slowly some rather delicate movement, 
such as threading a needle, or lifting a pin from a smooth 
surface, or by asking the child to remain in a standing 
position with both arms extended for a number of min- 
utes. Under this strain the choreic movements are mani- 
fested, and an early diagnosis is made. The early 
awkwardness of choreic children may sometimes be noted 
by their tripping, stumbling gait or by peculiar muscular 
contractions which momentarily distort the face. Very 
soon, however, following these early symptoms, unmis- 
takable and more or less general choreic movements 
develop, and then the diagnosis may be made at a glance. 

There is probably no more clearly defined or more 
characteristic symptom group than that of well-marked 
chorea. The involuntary, inconstant, incoordinate, 
jerky muscular contractions involving a whole or part 
of the body, and aggravated by efforts to control them, 
present an unmistakable syndrome. 

These irregular muscular movements vary greatly in 
severity. Mild as a rule in the beginning, and confined 
perhaps to one member of the body, in a short time they 
extend to the whole or half of the body and increase in 
severity, until at the end of the second week they have 



3l8 NEUROTIC DISORDERS OF CHILDHOOD 

reached their maximum severity. At this time in severe 
cases the muscular movements are almost constant, and 
the whole body may be undergoing bizarre movements 
which twist or distort the body to such an extent that 
the patient may be unable to maintain an upright posi- 
tion. The limbs are jerked and twisted in more or less 
constant movement, and every voluntary effort increases 
these incoordinate muscular contractions. 

In these severe cases the patients are kept in bed with 
great difficulty owing to the twisting spasmodic move- 
ments, which toss the child in various directions. These 
movements may be so severe that unless the patient is 
carefully protected, by constant watching or padded sides 
to the bed, he is likely to receive painful bruises, or worse 
injuries from being thrown to the floor, or knocked 
against hard objects. 

In the less severe cases the child may be able to go 
about as usual and have limited control of the spasmodic 
muscular movements, so that he is able to pick up a pin, 
button his clothes, or make letters with a pencil, but all 
voluntary movements of this kind are made after a few 
moments of deliberate preparation, and then the act is 
carried out with great rapidity. If, however, the move- 
ment requires any extended control of muscles, it usually 
fails, except, of course, in the mildest cases. 

Speech is commonly involved, the choreic movements 
extending to the tongue and muscles of the jaw. In 
these cases the articulation is imperfect and jerky. The 
patient hesitates and then speaks rapidly. The control, 
however, of the muscles of articulation may be lost in 
the middle of a word or sentence. In severe cases articu- 



CHOREA 319 

lation may be impossible, and in mild ones there may be 
little or no trouble in this regard. The muscles of 
deglutition may also be affected, producing difficulty in 
swallowing. The muscles of the larynx may in rare 
cases be affected, producing great irregularity in the tone, 
pitch, and volume of the voice. An effort to speak in 
these cases may produce a whisper, a barking sound, and 
other unusual noises. 

The diaphragm and other respiratory muscles may 
occasionally be affected, producing irregularity and loss 
of rhythm of respiratory movements. 

In severe cases of chorea the muscles become so ex- 
hausted by constant movement that they appear to be 
paralyzed. This extreme weakness of muscles, how- 
ever, is not common, and there is little or no change in 
their electrical reaction. An increased response to the 
faradic and galvanic currents has been claimed by some 
authors. 

Sleep quiets the choreic movements and gives time for 
the tired muscles to recover. 

Choreic movements become, as a rule, general. In 
about one-fourth of the cases, however, they are con- 
fined to one side of the body, but there is no apparent 
preference for the right or left side. These cases of 
hemichorea do not differ materially in any other particu- 
lar from those cases which involve the whole body. 

Choreic children are, as a rule, precocious, but the 
precocity is not infrequently associated with malnutri- 
tion, and is not therefore supported by a strength of body 
which will enable the child to undergo the mental and 
nervous strain into which its natural precocity leads it, 



320 NEUROTIC DISORDERS OF CHILDHOOD 

Among the children who hold the highest honors in 
school are to be found some of poor physique, who break 
down under the work and develop chorea and other 
neuroses in the spring of the year. Precocity therefore, 
coupled with physical inferiority, is commonly found in 
choreic children. 

Children of this type, even before the chorea has de- 
veloped, tire easily, are irritable, emotional, and suffer 
from headaches and general nervous irritability. After 
the chorea has developed all of these symptoms are 
exaggerated. 

Mental symptoms leading up to acute mania and mel- 
ancholia have been observed in a few cases. In not a 
small percentage of the cases the child's disposition is so 
changed, its mental irritability so greatly increased, and 
its moral sense so blunted, that it is not responsible for 
many acts of disobedience. These facts should be im- 
pressed upon the parents. 

The tendon reflexes in chorea are, in the majority of 
cases, normal. According to Sinkler, " In quite a con- 
siderable number the knee jerk is either absent or may 
be described as capricious ; that is, the knee jerks may be 
absent at one moment and at the next an involuntary 
movement of the child causes a reinforcement, and the 
response to a tap upon the patella tendon is prompt and 
energetic; there are some cases, however, in which the 
knee jerk cannot be developed under any circum- 
stances." 

Ancemia. — Well-marked anaemia is a very common 
symptom of chorea, and when present it is most im- 
portant that it should be properly interpreted, since it 



CHOREA 321 

indicates, as a rule, that severe nutritional disturbances 
are present, and are probably potent factors in the pro- 
duction of the chorea. Pronounced anaemias, due to 
severe disturbances of general nutrition, are present in 
at least a third of all cases. These cases may suffer from 
purpura, large purple bruises occurring over the body 
on slight injury; or they may have sores, slight wounds 
of all kinds being quick to suppurate and slow to heal. 
The skin may be dry, harsh, and sallow, and the patient's 
condition cachectic. Sufficient stress has not been laid 
upon the importance of the profound anaemias and mal- 
nutritions which are associated with chorea. This 
cachectic condition is to be looked upon as a most potent 
etiological factor, rather than as a secondary symptom. 

Heart Symptoms. — In every case of chorea the heart 
must be watched throughout for evidence of cardiac 
disease. A systolic or diastolic murmur may indicate 
endocarditis. At any rate, when murmurs are discovered 
the case is to be treated as one of endocarditis compli- 
cating chorea. In a few of these cases the murmur 
appears to be due to a weakness of the cardiac muscle, 
and in others it is probably purely haemic. Osier, how- 
ever, has called attention to the fact that many of the 
cases that are diagnosed as haemic are later found to be 
organic. The symptoms of pericarditis may also appear 
during or following the attack. 

TREATMENT 

Treatment of the Attack. — It is to be remembered that 
an attack of chorea is, as a rule, self-limited, and that 
mild cases can for the most part be satisfactorily treated 



322 NEUROTIC DISORDERS OF CHILDHOOD 

with very little medication. Our efforts in the begin- 
ning should be directed towards the control of the spas- 
modic muscular contractions, and to shortening the dura- 
tion of the paroxysm. 

In the beginning it is of the utmost importance that 
a most careful search for reflex exciting causes should 
be made. Eye-strain, adherent prepuce, and diseases of 
the throat, nose, and genito-urinary organs very com- 
monly act as exciting factors in developing an attack 
of chorea, and these organs should therefore be carefully 
examined and abnormal conditions be corrected. Above 
all, the intestinal canal should receive most careful con- 
sideration; a cathartic should be given, preferably 
calomel, followed by a dose of castor oil, to remove 
worms, foreign bodies, and undigested food. Intestinal 
fermentations should be corrected by proper food and 
medication. 

The diet in all cases is important. The food should 
be carefully selected safely within the range of the child's 
digestive capacity. Milk is an ideal diet, unless intes- 
tinal disease or an idiosyncrasy forbids its use. Chicken 
and beef in small quantities may be allowed, and cooked 
fruits and easily digested vegetables may be given to 
the milder cases. Among the articles of diet to be 
avoided may be mentioned coffee, tea, strong beef soups, 
sweets, and all indigestible food. 

Rest both of body and mind is necessary to the suc- 
cessful treatment of an attack of chorea. In the milder 
cases it is possible to get on fairly well without putting 
the child to bed, provided he is kept moderately quiet and 
not allowed to engage in any severe physical exercise. 



CHOREA 323 

Ordinary childish sports with other children are to be 
forbidden or carefully supervised and curtailed. In the 
severe cases the child should be put to bed and kept there 
until the paroxysm commences to subside, and there- 
after, until convalescence is established, should spend the 
greater portion of the time in bed. In the most severe 
cases confinement to bed is absolutely necessary for a 
period of three or four weeks, and in these cases the rail- 
ing about the bed should be high and well-padded to pre- 
vent the convulsive movements from throwing the child 
out of bed, or from otherwise injuring him by knocks 
against hard objects. The bodily rest which is so im- 
portant in the treatment of uncomplicated chorea is 
even more important when there is a concurrent endo- 
carditis; even the milder cases with this complication 
should be kept in bed. 

Mental rest is quite as important as bodily rest. Nerv- 
ous strain and mental work, which are ofttimes important 
factors in the production of chorea, should be reduced 
to a minimum in the treatment of these cases. The 
child should be taken out of school, and should in every 
way be protected against all forms of mental excitement. 
The tactful mother and nurse, when properly directed, 
will be able to interest the child without tiring or irri- 
tating him. 

Medical Treatment. — Arsenic Is the most valuable 
remedy we have in the treatment of the attack. It ex- 
ercises, in many cases, considerable influence in shorten- 
ing the attack. In giving arsenic one should commence 
with small doses, three minims, three times a day. After 
a few days of treatment, when it has been ascertained 



324 NEUROTIC DISORDERS OF CHILDHOOD 

that the arsenic will be tolerated, the dose is to be grad- 
ually increased, one or two drops a day, until at the end 
of the second week the patient is taking 15 to 18 
minims three times a day, or until the characteristic 
signs of arsenic poisoning are produced. These symp- 
toms are headache, an irritable stomach, diarrhoea, and 
puffiness of the face; and on the appearance of any one 
of these the arsenic is stopped for a few days, and then 
continued in smaller doses throughout the attack. There 
is no way of judging beforehand whether an individual 
attack of chorea will be benefited by the arsenic treat- 
ment. In only a small percentage of the cases does it act 
specifically in controlling the attack. In a larger per- 
centage, however, while its action is not so pronounced, 
it apparently exercises a favorable influence on the dura- 
tion of the attack. My own impression is that it acts 
better in the cases previously described as idiopathic 
chorea. It is not necessary, however, to continue these 
heroic doses of arsenic in a case where such treatment 
has made no impression upon the attack. If good is to 
be had from giving arsenic to the point of arsenical 
intoxication, the improvement will be made manifest by 
a single course of this kind of treatment. In those cases 
where this treatment fails to improve the patient, the 
arsenic should either be discontinued altogether or 
continued in small doses for the possible influence it may 
have upon the anaemia. 

Strontium salicylate and sodium salicylate (winter- 
green) and salol may be used in the treatment of an 
attack of chorea produced by rheumatism. These drugs 
are of undoubted value if symptoms of rheumatism 






CHOREA 3 2 5 

coexist with chorea, or if the attack of rheumatism has 
but shortly preceded the attack of chorea. 

In the treatment of all forms of toxic chorea occurring 
during, or shortly following, rheumatism and other 
infections, it is important that the child be put upon a 
milk diet and confined to bed, however mild the attack 
may be. Warm baths are indicated, and mildly laxative 
medication, preferably sodium phosphate, should be 
used. 

Idiopathic chorea associated with profound anaemia 
and malnutrition is to be treated with iron, cod-liver oil, 
and good food. Meat, eggs, and milk are especially 
indicated. As I have previously noted, many of these 
cases are due to concealed tuberculosis; but whether or 
not there be evidences of this disease, the iron is a very 
valuable remedy. It may be given in the form of sac- 
charated carbonate of iron, or in any one of the palatable 
and efficacious modern preparations. Under good-sized 
doses of iron, which may be combined with small doses 
of arsenic, many cases rapidly improve upon which the 
heroic arsenic medication has made no impression. 

Quinine is of value in those cases in which the chronic 
anaemia is due to malarial intoxication. 

By the treatment above described, attacks of chorea can, 
as a rule, be brought to an early and successful termina- 
tion. In the very severe cases, however, sedative medi- 
cation, which we avoid when possible, is absolutely 
necessary for successful treatment. Chloral hydrate, 
trional, and potassium bromide may be used to produce 
sleep, and hydrobromate of hyacine hypodermically, 
and chloroform by inhalation, may be used to control 



326 NEUROTIC DISORDERS OF CHILDHOOD 

the severe muscular contractions. Morphine hypoder- 
mically is absolutely necessary in the treatment of a few 
of the most violent cases. Jacobi says: "Very bad 
cases must be kept sleeping eighteen out of twenty-four 
hours by means of mild opiates or chloral hydrate, with 
or without bromides. Sometimes large doses are neces- 
sary, but the effect must be obtained. I have met with 
cases in which an occasional inhalation of chloroform 
was also required. Meanwhile, the symptomatic meas- 
ures adapted to the average case should also be at- 
tended to." 

Treatment of the Interval. — Following an attack of 
toxic chorea of rheumatic or other origin, the patient 
should have his nose and throat carefully investigated 
and any disease of these organs removed by proper 
treatment. Tonsils and adenoids enlarged by disease 
are portals through which infections enter the body, and 
they should therefore be removed to prevent second 
attacks of rheumatism or other infections from produc- 
ing a return of the toxic chorea. Rheumatic cases should 
also be carefully guarded by such hygienic measures as 
are used for the prevention of a return of this disease. 

In the treatment of those cases in which there is an 
underlying profound anaemia and malnutrition, the 
syrup of iodide of iron, cod-liver oil, fresh air, good 
food, and appropriate hygienic measures should be 
resorted to, in order to restore the patient to perfect 
health. 

In no instance should a case of chorea be dismissed 
as soon as the attack has disappeared. The attack should 
rather suggest to the physician's mind the importance 



CHOREA !3 2 7 

of searching for the disease of which the chorea is a 
symptom, and when the underlying disease has been 
determined, the physician should insist that appropriate 
treatment should be resorted to for a sufficient length 
of time to effect a cure, if this be possible. In this way 
second attacks of chorea may be prevented, and the 
general health of the patient ofttimes vastly improved 
over that which preceded the attack. 

When cardiac disease is associated with the attack of 
chorea it is, of course, of the greatest importance that 
the heart trouble should receive most careful attention 
after the attack of chorea has disappeared. 

Chorea, being a symptom group due to some grave 
constitutional disorder, may be considered a blessing in 
disguise, since it calls attention to and leads to the 
diagnosis and successful treatment of the underlying 
constitutional condition. If one look at chorea from 
this standpoint, one is sure to attach the greatest im- 
portance to the constitutional treatment of this disease. 



CHAPTER XXI 

HYSTERIA 

Definition. — Hysteria is a psycho-neurosis due to 
functional disturbances of the cortical centers. It is 
characterized by defective will-power, emotional excita- 
bility, and the control of body and mind by perverted 
notions and fixed ideas, which are not uncommonly 
produced by suggestion. 

PATHOLOGY 

Hysteria has no morbid anatomy, and its pathology 
is not definitely known. It is a real, not a simulated, 
disease of the cortical centers of the brain, the functions 
of which are perverted or wholly or partially lost. The 
lack of inhibition which results from the impairment of 
cortical centers diminishes or destroys the restraint 
which these centers normally exercise over the lower 
motor centers of the brain and cord, thus permitting 
them to be thrown into a state of wild excitement from 
slight causes. There is in hysteria, also, a lack of mental 
inhibition, which leads to the most violent mental excite- 
ment and emotional explosions from apparently trivial 
causes. 

The failure of voluntary (the will) and involuntary 
inhibitory centers to exercise normal restraint over both 
mental and motor acts is believed to be the important 

328 



HYSTERIA 329 

underlying pathological condition in hysteria. This 
defective development of inhibitory centers is made more 
potent for evil by the fact that in hysteria there is a 
hypersensitiveness and increased excitability of sensory 
and motor centers throughout the nervous system, due 
to heredity and nutritional disturbances. 

That the profound disturbances of the nervous system 
which occur in hysteria are functional, and not organic, 
is believed by all writers, and the transfer of motor and 
sensory disturbances from one part of the body to 
another lends strong support to this view. Apart, how- 
ever, from the changes which nerve cells exhibit under 
fatigue (see chapter, "Reflex Irritation") and mal- 
nutrition there is no definite pathology for this disease 
other than that above outlined. 

Hysterical symptoms, however, may be produced by 
organic diseases of the nervous system, and by all organic 
diseases which produce profound nutritional disturb- 
ances. The mechanism by which the hysteria is pro- 
duced in these cases is probably the same as that above 
outlined, and is not due to any specific lesion. In 
organic diseases hysteria is a complication which may 
lead to great confusion in diagnosis. 

ETIOLOGY 

'Age. — Hysteria is rarely met with before seven. 
From ten to fifteen it is common, but not so much so as 
in the adult. The milder forms of hysteria are seen 
more commonly than the severe in children, but if the 
diagnosis U made, as it should be, upon mild hysterical 



33^ NEUROTIC DISORDERS OF CHILDHOOD 

manifestations, the disease is not so uncommon in child- 
hood as one is led to believe by the literature. Hysteria, 
however, is not a disease of childhood. It is not only 
much more common, but much more severe, in the adult. 
In late childhood, however, from thirteen to seventeen, 
we may have the most pronounced and severe types of 
hysteria. 

The feeble inhibition of mental and motor acts is 
much more pronounced in the child than in the adult, 
but this factor does not become so active in producing 
hysteria until the mental and emotional centers are 
sufficiently developed to require inhibitory control. The 
cells exhibiting mental energy are very slowly devel- 
oped (see chapter " Physiological Peculiarities of the 
Nervous System in Childhood"), so that it requires the 
full period of twenty or twenty-five years to give them 
functional maturity. It is during the period from twelve 
to twenty-five, which sees the most rapid functional devel- 
opment of mental cells and of emotional faculties, that 
hysteria is most common and most severe. Hysteria 
occurs frequently in middle life, and may even continue 
into old age. These cases, as a rule, however, have begun 
in earlier life, and the manifestations in later life are 
either a continuance of or a relapse from these earlier 
attacks. Hysteria, however, may appear de novo in 
middle life. Clopatt gives the following table of the 
relative frequency of hysteria at different ages during 
childhood : 









HYSTERIA 














Girls. 


Boys. 


Total. 


In early 


childhood . 


• 19 


I 


20 


3 years 


. 


. — 


I 


I 


4 


(t 






, . 


. ' I 


I 


2 


5 


>( 




,1 \ 


H 


■ 4 


2 


6 


6 


c 




' \ 


H 


" 3 


2 


5 


7 


e 




I 


• 


15 


4 


19 


8 ' 


c 




! 


t 'i 

• 


16 


6 


22 


9 ' 


( 




1 


H _ 


15 


7 


22 


IO 


( 






H 

• 


18 


15 


33 


ii ' 


( 






1 1 


24 


17 


41 


12 ' 


{ 






* i 


22 


13 


35 


13 


e 






• 1 


27 


16 


43 


14 ' 


( 






• 


12 


8 


20 


15 ' 


t 






• • 


— 


3 
96 


3 






176 


272 



331 



Briquet found, by the analysis of statistics, that in 
the female one-fifth of the cases occur before puberty, 
one-third between the ages of fifteen and twenty, and that 
after twenty the frequency of hysteria rapidly dimin- 
ishes up to twenty-five years. From twenty-five to 
forty there is no diminution, but after forty the disease 
is infrequent. 

Heredity. — Excessively irritable mental, motor, and 
sensory centers, under feeble inhibitory control, which are 
the all-important pathological factors of hysteria, are in 
most cases largely a matter of heredity. That is to say, 
heredity is the great predisposing cause of hysteria. A 
strong neurotic taint is present in the family history of 



33 2 NEUROTIC DISORDERS OF CHILDHOOD 

most of these cases. There may be a family history of 
hysteria, chronic alcoholism, epilepsy, insanity, chorea, 
or other neuroses. The worst cases occur in families 
that are mentally degenerate. 

English, Germans, and Americans are believed to 
be less susceptible to this disease than the Latin races, 
and the Jews are especially inclined to hysteria. This 
is probably a matter of both heredity and environ- 
ment. 

Sex. — Hysteria occurs much more commonly in 
females, but the preponderance of females is not so great 
in children as in adults. According to hospital statistics 
of French writers, hysteria in the male is as common 
as it is in the female. This, of course, applies only to 
those of the lower classes, among whom the struggle for 
existence has proved a failure, as is evidenced by the 
fact that they are in charity hospitals. In America, 
hysteria, even among the poor, is much more common in 
women than in men. 

Malnutrition of nerve centers is by far the most im- 
portant direct cause of hysteria. The term malnutrition 
is here used very broadly, not only to include the innutri- 
tion of nerve cells which results from lack of sufficient 
food, but also the condition which results from a partial 
starvation of nerve cells, from their being supplied with 
blood deficient in some important ingredient, such as 
hemoglobin or oxygen. It also comprehends the condi- 
tion of nerve cells which results when they are fed with 
blood containing auto or intestinal toxins. Malnutrition 
of nerve centers, therefore, comprehends not only the 
condition which results from poor blood, but also that 



HYSTERIA 333 

which results from bad or poisoned blood. The blood 
state of all hysterical individuals demands the closest 
investigation, since the most important etiological fac- 
tors of this disease are to be found there. In the chapters 
on " Malnutrition," " Auto-intoxications," " Intestinal 
Toxaemias," and '' Bacterial Intoxications " I have dis- 
cussed the blood conditions which may, in susceptible 
individuals, be etiologically related to hysteria. 

Chronic tuberculosis is, on the whole, more closely 
related to hysteria than any other chronic disease. In 
some sections of the country chronic malaria is an 
important factor. All acute and chronic diseases which 
produce profound nutritional disturbances of the nerve 
centers, or irritate and poison these centers, over a long 
period of time, with auto or bacterial toxins, may, espe- 
cially in individuals who have inherited defective will- 
power and feeble control of the emotional centers, pro- 
duce hysteria. 

Chronic poisoning from alcohol, tobacco, lead, and 
mercury may be etiologically related to hysteria. In 
such cases it is possible that these poisons may act by 
producing general malnutrition, organic disease, or 
chronic irritation of nerve centers. 

Environment is the most important exciting cause of 
hysteria. Hysteria is more common in the city than in 
the country, not only because of the impure air and bad 
hygiene, but also because of the noise, the rush, and the 
strain of life in a large city. In the country the child 
may have, for a portion of the day, solitude and mental 
rest, both of which are necessary for the normal develop- 
ment of the nervous system. In the city he is subjected 



334 NEUROTIC DISORDERS OF CHILDHOOD 

to the constant excitement and mental activity with 
which our social order has surrounded him. 

The strain of school life and school examinations is a 
very important factor in developing hysteria. Children 
in our public schools must conform to a routine in con- 
finement, school work, and school examinations which 
the average child is able to withstand without material 
damage to his nervous system. Those children, however, 
below the average either in physical or mental ability have 
more or less trouble in keeping up with their classes, 
and are subjected to very great nervous excitement and 
mental strain by the periodic examinations, which may 
force them to acknowledge to their little world and their 
home circle that they have been reduced to a lower grade, 
and that they are not the equals of their fellows of the 
same age. This strain of school life and school exami- 
nations falls with greatest force on those that are least 
able to stand it — on the neurotic, malnourished child of 
poor physique. The routine of school work cannot be 
changed to suit the weaklings, the system must go on 
like a great machine, and must be adapted to the mental 
and physical capacity of the average child. If the weak- 
lings are not saved from this mental and physical grind, 
in which they may develop hysteria, chorea, or some 
other neurosis, it is not the fault of the machine, but 
rather of parents, guardians, and superintendents of 
schools, who should see to it that neurotic, malnourished 
children, if they go to public school at all, should be 
placed in a grade below that to which their age and 
mental capacity would admit them, thus putting their 
school work easily within both their physical and mental 






HYSTERIA 335 

capacity. In small private schools the routine is not so 
rigid, and there is a better opportunity on the part of 
teachers to give personal attention to the individual, pro- 
tecting precocious, neurotic children from overwork, and 
stimulating dull, vigorous children to increased mental 
work. For these reasons, children who are below the 
normal average, either in mental or physical ability, do 
best under home instruction or in small private schools. 

Lack of home discipline, which allows self-indulgence 
and free play to the emotions, may prepare the child for 
the development of hysteria. On the other hand, home 
training and school discipline, which teach the child 
to control his emotional nature, and which protect him 
from influences that excite the emotions and harass the 
mind, and which educate him not to act precipitately in 
the heat of passion or under emotional excitement, but 
to withhold his resentment until his passions and emo- 
tions are well under control, may prevent the develop- 
ment of hysteria even in children more or less predis- 
posed to this disease by heredity and malnutrition. In 
the chapter on " Excessive Nerve Activity " I have more 
fully discussed the relationship of school life to hysteria 
and other neuroses. 

Excessive nerve activity and mental strain are potent 
factors also in developing hysteria in adults. Business 
and household cares and worries, when long continued 
without periods of rest, may in susceptible individuals 
develop hysteria. The close association of members of 
a neurotic family creates a nervous atmosphere very 
conducive to the development of hysteria; under such 
conditions the principle of imitation may produce an 



336 NEUROTIC DISORDERS OF CHILDHOOD 

epidemic resulting in a number of cases in the same 
family. Business misfortunes, plunging families from 
positions of influence to dire poverty, necessitating an 
entire change of surroundings and the giving up of 
associations that seem necessary to happiness, and the 
facing of trials incident to a struggle for existence, may 
be exciting causes of hysteria. Great grief, such as 
follows the loss of one who has been the mainstay of a 
family, with the cares and responsibilities which follow, 
may, in the physically weak and irresolute, produce 
hysteria. Disappointment in love and religious excite- 
ment are not uncommon exciting causes. The excite- 
ment, gloom, privations, mental anxieties, and nervous 
strain incident to great wars may be a widespread 
cause of hysteria and other neurotic diseases. 

Fright, such as may result from fires, cyclones, earth- 
quakes, lightning, panics, or the witnessing of some 
awful catastrophe may develop hysteria in those pre- 
disposed to this disease by malnutrition or heredity. 

Trauma. — Severe forms of hysteria may be produced, 
or perhaps it may be better to say developed, by injuries 
resulting from explosions, railroad accidents, and other 
causes likely to produce severe nervous shock. In such 
cases it is difficult to say whether fright or shock is 
the exciting cause of the hysteria. 

SYMPTOMATOLOGY 

Extreme selfishness and dependence masquerading 
under the cloak of self-sacrifice are common manifesta- 
tions of hysteria. 



HYSTERIA 337 

The hysterical patient is very exacting of all around 
her, and in narrating her own sufferings she tells of 
the sacrifices which she makes for the comfort of others, 
when in truth she does not hesitate to call upon those 
around her to sacrifice themselves to administer to her 
apparently trivial ailments. The selfishness of hysteria, 
however, is a part of the disease, and not within the 
control of the patient. The selfishness, therefore, being 
more apparent than real, can hardly be spoken of as true 
selfishness. It is a defect in will-power which makes 
the hysterical patient so dependent upon those around 
her. She is often controlled by fixed ideas with reference 
to her inability to act and think for herself. She cannot 
do those things which others have been in the habit of 
doing for her because a perverted notion to that effect 
controls her. 

One of the most peculiar and characteristic examples 
of the control which fixed ideas have over hysterical 
patients is shown in the symptom group known as 
astasia-abasia. This is one of the most common of 
hysterical manifestations, and is produced by the fixed 
idea in the patient's mind that she cannot either stand 
or walk. She may have perfect control of her legs when 
lying down, moving them at will in any direction, and 
not manifesting any muscular weakness, but the minute 
she is placed upon her feet her legs give way; or they 
may stiffen, the patient losing her equilibrium; or she 
may stand upon her feet and not be able to walk, making 
wild, incoordinate movements of the legs when she at- 
tempts to do so. In other instances, the fixed idea may 
confine the patient to bed for months or years, or it may 



33^ NEUROTIC DISORDERS OF CHILDHOOD 

cause her to avoid light, remaining constantly in a 
darkened room. Some perverted notion or fixed idea 
is a large factor in producing symptoms in almost every 
case of hysteria. 

Perhaps the next most characteristic symptom group 
of hysteria is that produced by emotional excitability. 
Hysterical patients are very emotional; fits of crying 
and laughing may follow each other without apparent 
cause. They are moody, irritable, and are easily thrown 
into states of great nervous excitability. In extreme 
cases the mental excitability and sleeplessness may pass 
into a state of acute mania, with absolute loss of reason. 
These severe mental symptoms not uncommonly follow 
attacks of hysterical convulsions. 

The hysterical patient may lose her temper, may pass 
into a state of ecstasy, may pass into a state of gloom, 
may be wildly excited, or made pallid with fear from 
causes that would produce no such results in a well- 
balanced nervous system under proper inhibitory control. 

Suggestion is one of the most potent factors in 
developing symptom groups in hysterical patients. The 
susceptibility to this influence marks one of the most 
important characteristics of the hysterical mind. Syn- 
dromes may be suggested to hysterical patients by the 
questions of the examining physician, and at the next 
visit symptoms may be present which the patient has 
learned might develop. The story of another's symp- 
toms and sufferings may suggest the same symptoms 
to the hysterical mind, and they promptly appear. In 
a thousand ways these suggestions may come not only 
from without but also from within. The hysterical 



HYSTERIA 339 

patient may come out of a dream, a convulsion, or a 
trauma, with hallucinations which may be productive of 
paralysis, anaesthesia, loss of voice, or in fact almost any 
of the multitude of hysterical symptoms. 

Paralysis is a common manifestation of hysteria in the 
adult, but it is comparatively rare in young children. In 
late childhood, however, it is not infrequently observed. 
The slighter forms are more common in the child than 
the severe types so frequently witnessed in the adult. 
The paralysis may be flaccid, with diminished reflexes 
and occasionally an absence of the knee jerk. The spastic 
form, however, associated with contractures and exag- 
geration of deep reflexes is much more common. The 
exaggeration of reflexes, however, is not so marked as 
in spastic paralysis of organic origin. 

The paralysis may vary in form from a slight weak- 
ness of a few muscles to complete paralysis of almost 
all the voluntary muscles. It may be hemiplegic, para- 
plegic, monoplegic, or it may be irregularly distributed, 
involving only certain groups of muscles. Hysterical 
paralysis is rarely complete. As a rule, it is partial, and 
accompanied by muscular contractions, which give rise 
to a great variety of symptoms. 

Paralysis of the muscles of the face may produce a 
lack of symmetry in the two sides; of the foot, club- 
foot; of the wrist and hand, wrist-drop, and various 
contractures; of the neck, torticollis; of the back, curva- 
ture of the spine; of the mouth, dropping of its angle 
and drooling; of the larynx, aphonia. 

Hysterical aphonia, which is frequent in childhood, is 
one of the most common and easily recognized symptoms 



34° NEUROTIC DISORDERS OF CHILDHOOD 

of this disease. The voice may be lost very suddenly 
and may return as quickly. The aphonia may continue 
for days, months, or years. It may disappear under a 
strong faradic brush applied over the trachea, or it may 
resist all forms of treatment. Complete paralysis of the 
vocal cords and laryngeal muscles, resulting in absolute 
mutism, may occur in the child, but not so frequently 
as it does in the adult. 

Paralysis of the tongue may produce disturbances of 
speech; of the eye, squint; of the diaphragm, singultus; 
of the respiratory muscles, cough, dyspnoea, and other 
disturbances of respiration; of the oesophagus, dys- 
phagia, regurgitation of food, and globus hystericus. 
The globus hystericus is perhaps the most common of 
all hysterical manifestations, in children as well as in 
adults. The hysterical cough, persistent, dry, harsh, and 
easily excited by suggestion, is a very common and very 
troublesome symptom. To those constantly associated 
with hysterical patients the cough and the hiccough are 
perhaps the most trying and exasperating of symptoms. 

Tremor is a peculiar motor symptom, which occurs 
not infrequently in traumatic hysteria, and may also 
occur in hysteria from other causes. Tremor may per- 
sist for years, and is a very distressing symptom. The 
tremor is manifested especially in the hands, but may be 
more or less general. 

Incontinence of urine and faeces are very rare in 
hysteria in the adult. In the child they are not so un- 
common. When they do occur, however, they are 
intermittent, and not constant, as in organic disease. 

Hysterical paralyses in their duration, development, 



HYSTERIA 341 

and disappearance follow no rules. They may last fon 
days or years; they may occur very suddenly or they 
may be very slowly developed. They may disappear 
almost instantly or there may be gradual recovery; they 
may come, go, and again return ; they may shift from one 
part of the body to another, not following the rules of 
organic paralysis. 

Diagnosis of hysterical from organic paralyses can, 
as a rule, be made very readily. Hysterical paralysis, as 
above noted, does not conform to anatomical laws of 
distribution. Hysterical hemiplegia, which so closely 
resembles in distribution the organic form, may not be 
associated with aphasia, paralysis of the tongue, an 
exaggeration of deep reflexes, and is accompanied by 
more marked sensory changes than those occurring in 
organic hemiplegia. 

In the flaccid palsies of hysteria there is no change in 
electrical reactions. The reflexes, as a rule, are not 
lost ; the sensory disturbances are very marked, and other 
hysterical symptoms are present. 

Ancesthesia, which is one of the most common hysteri- 
cal manifestation in the adult, is not so common in the 
child. It occurs, however, not infrequently in older 
children, and is, as a rule, associated with paralysis of 
the part affected. 

The distribution of the anaesthesia is one of the strong- 
est aids in the differential diagnosis of hysterical from 
other anaesthesias. It is commonly confined to one-half 
the body, preferably the left side. This hemianaesthesia 
is profound, confined strictly to one-half the body, and 
comprehends not only absolute anaesthesia to all forms 



34 2 NEUROTIC DISORDERS OF CHILDHOOD 

of ordinary sensation, but is also accompanied by loss 
of hearing, seeing, smelling, and tasting on the affected 
side. The line of demarcation between the anaesthetic 
and the normal sides is sharply defined, extending from 
the top of the head to the feet, involving general sensa- 
tion and the special senses. The anaesthesia is not con- 
fined to the skin, but extends to deeper tissues. The 
patient is not always conscious of the location, extent, 
an*d character of the anaesthesia, showing that conscious 
impressions are not necessary to its development. Hemi- 
anaesthesia, however, may be transferred from one side 
of the body to the other under influences of suggestion. 
The anaesthesia, as a rule, returns to the side first affected. 

The anaesthesia and hysteria may also be regional, 
confined to a limb or to small portions of the body. 
Anaesthesia of a limb is, as a rule, associated with 
paralysis, and is sharply defined by a line running 
around the limb. In its disappearance this line may 
slowly pass down the limb, or the anaesthesia of the 
whole limb may suddenly disappear. Small spots of 
anaesthesia may occur; these islands are usually round 
or oblong, and may vary in size from a few inches to 
a foot in diameter. In rare instances hysterical anaes- 
thesia may involve almost the entire body. An absence 
of tactile, thermic, or painful impressions, or a loss of 
the muscular sense — any or all of these may constitute 
hysterical anaesthesia. 

Hyperesthesia is one of the most common of the 
sensory disturbances in children. It is most commonly 
observed over the spine, ovaries, breasts, and abdomen. 
The slightest touch or injury to the skin over these areas 



HYSTERIA 343 

may produce pain, convulsive disorders, and other hys- 
terical manifestations. In children, however, the milder 
hysterical phenomena follow pressure in these hystero- 
genic zones. 

Painful joints, simulating inflammatory diseases, is 
one of the most common of the hyperesthesias of child- 
hood. Hysterical disease of the hip or knee joints is 
not uncommon between the ages of ten and fifteen, and 
occasionally occurs in very young children. The simi- 
larity between hysterical and organic diseases of joints 
is so great that mistakes in diagnosis are frequent. The 
pain on motion and the tenderness on pressure are 
greater in the hysterical joint, but the deformity, con- 
tracture, and apparent shortening disappear when the 
patient is anaesthetized, and these facts, together with the 
presence of paralysis of the part affected, or other hysteri- 
cal manifestations, suffice to make a differential diagnosis. 

Closely associated with hysterical joint disease are the 
hysterical contractures, which may be confined to one 
limb or may involve a number. A contracture may be 
so strong that no movement of the joint whatever can 
be produced. In other instances there is limited move- 
ment, not allowing complete flexion or extension. These 
contractures may involve the muscles of the face, tongue, 
and neck, as well as those of the body and extremities. 
The thighs may be flexed upon the abdomen, or the arm 
upon the forearm, and any attempt at overcoming these 
contractures may produce great pain. Some of these 
cases are very puzzling as to diagnosis, but as they are 
usually associated with other well-marked hysterical 
symptoms which lead us to suspect their nature, an 



344 NEUROTIC DISORDERS OF CHILDHOOD 

anaesthetic under which these contractures subside 
suffices to differentiate them from organic contractures. 

Disturbances of special senses are not infrequent in 
hysteria. It was above noted, in speaking of hemiplegia, 
that the special senses on one side may be completely or 
partially lost, while on the other side they remain normal. 
In this condition the patient may be blind in one eye, 
deaf in one ear, and in one-half the tongue the sense of 
taste may be absent, and in one nostril the sense of smell 
may be gone, and over the skin of one-half the body 
the sense of touch may be lost. Besides these unilateral 
disturbances of the special senses, there are others affect- 
ing the special senses of both sides, and not necessarily 
associated with hemiplegia and hemianaesthesia. On the 
part of the eye there may be photophobia, color blind- 
ness, and absolute or partial loss of sight. Complete 
blindness is rare and transient, but partial blindness, pro- 
duced by peculiar and irregular contractions of the visual 
field, is not infrequent. Hysterical disturbances of hear- 
ing, smelling, and tasting are much less commonly in- 
dependent of a general hyperaesthesia and anaesthesia than 
are those of sight. An exaggerated acuteness, as well as 
diminution or obliteration of the special senses, may 
occur on one or both sides, entirely apart from other 
sensory disturbances. 

Eclampsia is the most striking of the motor manifes- 
tations of hysteria. The hysterical fit or convulsion has 
been commonly spoken of and described under the term 
hystero-epilepsy, from the fact that the paroxysm may 
somewhat resemble that of true epilepsy. 

Hysterical eclampsia is usually heralded for a number 



HYSTERIA 345 

of days by some of the psychic symptoms previously 
noted, and is commonly followed by sensory disturb- 
ances. Immediately preceding the paroxysm of eclamp- 
sia a group of symptoms peculiar to the individual 
announce the onset of the fit. Among such aura of hys- 
terical convulsions may be mentioned a sensation of 
suffocation, severe headache, abdominal pain and vomit- 
ing, globus hystericus, ringing in the ears, or an in- 
creased sensitiveness over the ovaries, or over some of 
the other hysterogenic areas, pressure over which may 
start the chain of hysterical symptoms, culminating in 
eclampsia. 

Hysterical eclampsia is very uncommon in the child. 
It does occur, however, in older children, and about 
puberty is not so rare. The seizure may be ushered in 
by a cry, and during the attack the patient may scream 
or make other noises. The convulsion is at first tonic, 
producing oposthotamus, the back and limbs stiffening 
and curving like a bow. This stiffening gives way to 
clonic convulsions, and the body is jerked and tossed 
about by violent muscular contractions. In a short time, 
from five to ten minutes, the convulsive movements cease 
and the patient is relaxed, and often falls into a light sleep, 
to awaken shortly in a state of emotional excitement. 
This stage gives the impression of conscious deception 
by its strange talk and bizarre movements. In the final 
stage there may be a period of semi-consciousness or 
deliriunx 

In other cases the convulsive movements are imme- 
diately followed by a profound sleep or trance lasting 
for hours, from which the patient may awaken with 



346 NEUROTIC DISORDERS OF CHILDHOOD 

paralysis, contractures, or anaesthesia of all or part of 
the body. The emotional element before, during, and 
after the attack is much more marked than in epilepsy, 
and the loss of consciousness is less profound. Hyster- 
ical convulsions may, in some cases, be modified or 
stopped by pressure or electricity applied to some of the 
hysterogenic areas; this is not true of epilepsy. Incon- 
tinence of urine and faeces does not occur, the tongue 
is not bitten, and the patient's subconsciousness seems 
sufficient to protect him from injury; he falls softly; he 
does not toss himself against hard objects, although he 
seems on the point of doing so. This strange subcon- 
sciousness that protects the patient in hysterical convul- 
sions often leads to the unwarranted conclusion that 
there is an element of conscious deception in the attack. 
While the severe convulsive seizures above described 
are comparatively rare in the child, mild convulsive 
attacks, with partial loss of consciousness and character- 
ized by strange and apparently purposive movements, 
are not uncommon. During such attacks the patient 
may continue to perform some special movement, such 
as the flexing of an arm or leg, or retraction or rotation 
of the head; or he may jump about the bed in mimicry 
of some animal ; he may bark, bite, and snarl like a dog 
as he tosses the bed clothing; but he does not injure 
himself or others. In other cases the patient may lie 
in one position, dazed or semi-conscious, with eyes open 
and fixed. There may be localized spasm of almost any 
muscle or group of muscles, producing " chorea major " 
or localized movements. Some of these movements of 
voluntary muscles seem to be purposive, but that they 



HYSTERIA 347 

are not so is indicated by the fact that localized convul- 
sive movements occur in involuntary muscles. Spasm 
of the diaphragm may produce hiccough, which may be 
a very distressing and troublesome symptom; spasm of 
other respiratory muscles may produce very rapid 
breathing and dyspnoea; spasm of the esophagus may 
produce difficulty in swallowing and globus hystericus : 
spasm of the muscles of the intestines may produce 
diarrhoea. 

The emotional element is great in all hysterical at- 
tacks, and they not unusually terminate in fits of laugh- 
ing or crying. The more profound mental disturbances, 
such as catalepsy, lethargy, trance, and ecstasy, which 
may occur in the adult, either associated with or inde- 
pendent of the hysterical convulsion, are rare in the 
child. 

Hyperpyrexia is sometimes observed, and fever is not 
unusual in juvenile hysteria. Some remarkable cases 
of hyperpyrexia have been reported. Jacobi reports one 
in which the temperature reached and continued above 
lio° F. for days. 

Visceral Symptoms. — Anorexia nervosa is a classical 
symptom group produced by hysteria. In this condition 
the patient may go for weeks without being seen to 
retain any food; the sight of food may produce nausea, 
or all food taken may be vomited, and sometimes with 
a conscious effort. The severity of these symptoms may 
vary from slight nausea to a nausea so profound that 
all food is refused or rejected after being taken and the 
patient brought to the point of starvation. 

Paralysis of the bowels may produce constipation. In- 



34-8 NEUROTIC DISORDERS OF CHILDHOOD 

creased peristalsus may cause diarrhoea. Enormous 
distension of the stomach and bowels may occur; phan- 
tom tumor of the abdomen, produced by gaseous disten- 
sion, is not uncommon. 

A very large quantity of light-colored urine of low- 
specific gravity may be passed by hysterical patients. 
Anuria has also been noted. 

TREATMENT 

In beginning the treatment of a case of hysteria it 
is most important that all physical causes that may have 
contributed to the production or the continuance of the 
disease should, if possible, be removed. A careful search 
should be made for causes of reflex irritation to the 
nervous system. Eye-strain, diseases of the nose, 
throat, reproductive and genito-urinary organs should 
receive appropriate treatment. While these factors, if 
they exist, may not have been of prime importance in 
the development of the disease, there can be no doubt 
that they may exercise an influence in continuing the 
hysterical condition, and in precipitating hysterical par- 
oxysms. In the child, eye-strain, and, in the adult, 
diseases of the reproductive organs are the most common 
sources of reflex irritation, associated with and etiolog- 
ically related to hysteria. 

The next step in the treatment comprehends a search 
for and the removal of the underlying causes of the 
chronic anaemias or malnutritions so commonly found 
in hysterical patients. If marked malnutrition exist, it 
is one of the causes of the extreme excitability of the 
nervous system which is an important factor in pro- 



HYSTERIA 349 

ducing the hysteria. The malnutrition factor is espe- 
cially important in the hysteria of childhood, and may 
be produced by a concealed or lymph node tuberculosis, 
a chronic malaria, some form of chronic auto-intoxica- 
tion, or chronic intestinal toxaemia; or it may be purely 
a question of improper food, impure air, and unhygienic 
surroundings. At any rate, it is most important in the 
treatment of hysterical patients presenting evidences of 
nutritional disturbances that every attention should be 
given to improving the physical condition of the patient. 
In order to do this it is not only necessary to prescribe 
medicines suitable to the individual case, such as iron, 
cod-liver oil, arsenic, quinine, or some tonic that will 
stimulate the appetite and improve digestion, but it is 
of even greater importance that diet and general hygiene 
should be as carefully prescribed. 

There is, of course, no diet belonging to hysteria 
proper, but one can say, in a general way, that alcohol, 
tea, coffee, concentrated sweets, salads, pastries, rich and 
highly seasoned dishes, are to be avoided, and a diet 
simple, wholesome, and nutritious prescribed, suitable 
to the digestive capacity of the patient and the character 
of the malnutrition from which she suffers. In addition 
to this, the hysterical patient should live as much as pos- 
sible out of doors, away from the whirl, noise, and ex- 
citement of a large city. Moderate exercise and con- 
genial surroundings are also important. In brief, every 
attention should be directed towards improving the 
physical condition of hysterical patients, since the 
mental condition is largely a reflex of physical dis- 
abilities. 



35° NEUROTIC DISORDERS OF CHILDHOOD 

The mental condition, however, of hysterical patients 
must also be carefully and tactfully treated. Whatever 
may have been the surroundings under which the 
hysteria developed, a complete change is to be recom- 
mended, not only for the purpose of avoiding the 
etiological factor that produced the hysteria, but also 
to get the benefit of the marked and not altogether 
understood curative influence which a change of sur- 
roundings has on these cases. All mental stimulation 
must be stopped at once, school life, as well as home 
instruction, for mental development must be discontin- 
ued, and the patient (child or adult) should, if possible, 
be separated from her family. This is especially impera- 
tive if other members of the family are strongly neurotic, 
as in the majority of cases they are. The removal from 
the nervous atmosphere of a neurotic household, the 
stopping of all mental stimulation and avoiding nervous 
excitement, are important factors in the cure of hyster- 
ical patients, but the removal from home comprehends 
not only these curative influences, but also the powerful 
influence which is exerted by placing the patient under 
entirely new conditions. If, for example, the patient is 
sent to a hospital, the going to bed, the presence of 
trained nurses, the routine of treatment, which may 
include hydrotherapy and massage, the regular visits of 
the tactful physician, and all the machinery which moves 
as he directs, makes a powerful mental impression upon 
and inspires confidence in the patient, which is the first 
and all-important step in the cure. 

The new surroundings which are thus produced by 
change, when tactfully used by the physician, constitute 



HYSTERIA 351 

a form of suggestion, and this is, after all, the most 
potent agent we have for the cure of hysteria. As 
previously noted, suggestion is one of the most power- 
ful factors in developing hysterical paroxysms, and it 
is also, probably, the most powerful agent we have for 
controlling these same paroxysms. The hysterical pa- 
tient should be under the influence of a nurse or com- 
panion whom she loves and in whom she has confi- 
dence. 

This attendant should be of good physique, of strong 
will, of sober mind, and full of tact ; and she should have 
sufficient intelligence to study the peculiarities of her 
patient's mental condition so that she may tactfully 
avoid touching upon topics which, by suggestion, may 
influence her patient unfavorably, and so that she can 
utilize the fads and idiosyncrasies of her patient in such 
a way as to help her keep her mind from dwelling upon 
her own troubles. The majority of hysterical patients 
desire to get well, and they desire to be surrounded by 
people and by influences which help to convince them 
that they are going to get well. The successful treat- 
ment, therefore, of hysterical patients will depend largely 
upon the ability of the physician to so control the sur- 
roundings of his patient that she will be constantly in- 
fluenced by wholesome suggestions — suggestions that she 
is improving from time to time, and that her early re- 
covery is assured. The influence of change is so potent 
in the treatment of hysterical patients that it is necessary 
that radical changes should be made in the surroundings 
from time to time. The wholesome surroundings of a 
new location after a certain length of time become mere 



352 NEUROTIC DISORDERS OF CHILDHOOD 

routine, and routine wears upon the nervous system of 
hysterical patients. 

In beginning the treatment of severe cases of hysteria 
the Weir Mitchell Rest Cure is often of great ad- 
vantage. The confinement to bed, massage, forced 
feeding, isolation, and striking change of surroundings 
which this treatment comprehends act not only by sug- 
gestion upon the mind of the patient, but the treatment 
itself is especially adapted to many cases. 

Hydrotherapeutics, in some form, is applicable in the 
treatment of nearly every case of hysteria. The cold 
tub-bath or the cold douche to the spine will often bring 
a patient out of a severe paroxysm of hysteria. This 
treatment, however, is applicable not only in overcoming 
severe symptom groups of hysteria, such as trance, 
paralysis, and mental despondency, but in many cases 
it acts as a tonic to the nervous system, and should be 
continued as a part of the routine daily treatment. The 
alternate hot and cold bath is applicable in some cases. 
The hot bath, followed by general massage and an alco- 
hol rub, is of very great advantage in many cases. The 
operator must be carefully selected and carefully in- 
structed in these cases; she must have explained to her 
the powerful influence of suggestion in the treatment of 
hysteria, so that she, by her manner and conversation, 
may strengthen the patient's confidence in her physician, 
and convince her that just this particular treatment has 
cured many other cases exactly like hers. 

Electricity is one of our most valuable agents in the 
treatment of hysteria, and it acts largely by suggestion. 
This fact should be kept in mind in giving electricity, 



HYSTERIA 353 

and all legitimate means to make the suggestion as 
strong as possible should be used. The method of appli- 
cation, the size of the electrical apparatus, and the prepa- 
ration of the patient's mind for the treatment may be 
influences that work for good or evil in the giving of 
electricity; but after all it is the tact and personal 
magnetism of the operator that counts for most in these 
cases. 

In the treatment of aphonia and paralyses of various 
kinds it may be necessary to use the electric brush, at 
the same time impressing the patient that, while the 
operation is painful, it is wonderfully efficacious in the 
cure of the condition from which she is suffering. The 
electric brush performs wonderful cures in some of these 
cases. Apart, however, from the power of suggestion 
and the dread of treatment, it is not exactly clear how 
it may act upon the hysterical mind. 

Surgical operations and injuries of any kind may 
exercise a temporary wholesome influence upon hyster- 
ical symptoms. Blistering the skin for the relief of pain 
and cauterizing the spine for tenderness are of benefit 
in some cases. 

Pressure over the hysterogenic areas, such as the 
ovaries, may sometimes cause sudden recovery from a 
severe hysterical paroxysm. 

Sedatives play a very unimportant role in the treat- 
ment of hysteria, and it is doubtful whether they ever 
do any real good. The bromides and valerian, however, 
may be used for the relief of symptoms, but they should 
not be continued for any length of time. The hysterical 
patient, under no conditions, should depend upon seda- 



354 NEUROTIC DISORDERS OF CHILDHOOD 

tives for the relief of nervous symptoms. They aggra- 
vate, rather than control, the underlying pathological 
conditions of the disease. Hysterical patients, however, 
may be given a tonic suitable to their condition, and 
they may be impressed with the idea that this tonic has 
remarkable sedative and curative powers. The medical 
treatment, like the other forms of treatment, largely 
depends for its efficacy on suggestion. 



CHAPTER XXII 

HEADACHES 
ETIOLOGY 

Age. — Headaches are very uncommon in children un- 
der five years of age, but when they occur they are, as a 
rule, due to some intercranial organic disease or to dis- 
ease of the internal ear. After five years of age head- 
aches become more frequent, so that between the ages of 
eight and fourteen they are very common, but even dur- 
ing this period they are nothing like so common as they 
are between the ages of twenty and forty, this being the 
period of selection for neuralgic, neurasthenic, and mi- 
grainous headaches. 

Sex is a very noticeable factor in producing headaches 
after the fourteenth year of life, women suffering more 
commonly than men, in the ratio of 3 : 1 ; but in early 
childhood sex has little influence. 

Heredity. — A neurotic inheritance predisposes to head- 
aches. This is especially true of migrainous, neuras- 
thenic, and neuralgic headaches. These cases commonly 
have a family history of gout, migraine, neurasthenia, 
hysteria, or general nervous instability. Feebleness of 
constitution due to chronic diseases in the parents may be 
inherited by the child and predispose it to reflex, toxic, 
anaemic, and other varieties of headache. 

Anaemic Headache. — Anaemia and malnutrition are 
such potent factors in producing headaches that all writers 
upon this subject discuss anaemic headaches. All of the 

355 



356 NEUROTIC DISORDERS OF CHILDHOOD 

various forms of malnutrition so common in infancy and 
childhood, produced by tuberculosis, hereditary syphilis, 
gastro-intestinal diseases, constipation, rheumatism, ma- 
laria, bad hygiene, and improper food, have as one of 
their most characteristic symptoms a profound anaemia 
and a general instability and irritability of vasomotor 
and other nervous centers. This condition is a very 
powerful predisposing factor to headaches and the other 
neuroses of childhood. Malnourished, anaemic, neurotic 
children may have headaches from such slight exciting 
causes that these causes may be overlooked. It is per- 
haps better to consider anaemia as a predisposing rather 
than as an exciting cause of headaches, since anaemia is 
but one of the signs of the general malnutrition of nerve 
and other tissues which predispose these children to 
headaches, and since this condition is commonly as- 
sociated with important exciting factors which otherwise 
may be overlooked. In the treatment of headaches in 
anaemic children, however, it must always be kept in mind 
that these cases cannot be successfully treated unless the 
underlying malnutrition is removed. The removal of 
the exciting causes in these cases may relieve the head- 
aches, but it does not remove the predisposing cause. 

Neurasthenic Headaches. — Neurasthenia is, like anae- 
mia, a powerful predisposing cause of headaches. This 
factor is, however, more commonly found in older chil- 
dren. The neurasthenic condition in children is largely 
dependent upon malnutrition of the nervous centers and 
upon neurotic inheritances, and is developed by subject- 
ing this kind of a nervous system to mental overwork, 
nervous strain, and emotional excitement. These factors 



HEADACHES 357 

bring about an exhaustion and functional incapacity of 
nerve centers which we call neurasthenia, and which 
has as one of its characteristics the development of head- 
aches from slight exciting causes. 

Among the exciting causes which may develop head- 
ache in anaemic and neurasthenic children are nervous 
and emotional excitement, nervous and physical fatigue, 
nervous shock, fear, anger, mental overwork, the strain 
and confinement incident to school life, as well as the or- 
dinary toxic and reflex factors presently to be discussed. 
Such causes as these may in neurotic and malnourished 
children with vasomotor instability produce fluctuations 
in the blood supply of the brain, thus producing conges- 
tive or hyperaemic headaches. In older girls the men- 
strual period may act in a similar way in producing very 
severe headaches. Congestive and other types of head- 
ache occurring in anaemic and neurasthenic children are 
usually vertical, and the pain is dull and boring in charac- 
ter. They are commonly associated with vertigo or a 
feeling of faintness, and may be relieved by the ap- 
plication of cold to the head and nerve sedatives, such 
as the bromides. 

Reflex headache is perhaps the one form of headache 
which is more common in childhood than in adult life, 
and this is because the immature and unstable nervous 
system of the child responds more readily to reflex stimuli 
than does the stable and mature nervous system of the 
adult. 

Between the ages of six and fourteen eye-strain is a 
very common cause of headache. Errors of refraction 
and strabismus are very frequent in young children, and 



35 8 NEUROTIC DISORDERS OF CHILDHOOD 

are commonly overlooked until the child goes to school. 
Here sooner or later, if there be any marked ocular defect, 
the eye-strain will make itself known by a headache at 
times so severe as to make it impossible for the child to 
use his eyes sufficiently to do his school work in a satis- 
factory manner. Under these conditions he becomes 
nervous, irritable, dislikes his school, and suffers from a 
headache more or less severe and chronic in character. 
It is located, as a rule, in the forehead or between the 
eyes. It may, however, involve other portions of the 
head. It comes on after using the eyes for some length 
of time, and grows more severe towards the close of the 
school day. It disappears or at least is very much better 
in the morning, after the eyes and the nervous system have 
had a night of rest. It should be remembered, however, 
that while eye-strain is a very important factor in pro- 
ducing headaches in children, — so important, in fact, that 
it is at times the only apparent cause of this condition, — 
yet in the majority of instances where this factor is present 
it is assisted by other and more important factors. In 
every instance, therefore, where eye-strain is found 
to be present as an apparent cause of headache, a careful 
search should be made for other possible causes. Anaemic, 
neurasthenic, and toxic headaches may be developed or 
greatly aggravated by eye-strain and other reflex factors. 
In the chapter on Migraine I have called special atten- 
tion to the secondary role which reflex factors may play 
in precipitating and aggravating this particular type of 
headache, and here again I wish to insist that a neurotic 
inheritance and chronic malnutrition producing an insta- 
bility of vasomotor and other nerve centers is, as a 



HEADACHES 359 

rule, the basis of reflex headaches, and plays quite as 
important a role in their production as the reflex factor 
itself. Among the causes other than eye-strain for 
reflex headaches may be mentioned adenoid growths and 
other diseases of the naso-pharynx, phimosis with ad- 
herent prepuce, and foreign bodies and undigested food in 
the intestinal canal. 

Toxic headaches are very common in childhood, es- 
pecially those of gastro-intestinal origin. Undigested 
food and the irritating and toxic products produced by 
gastro-intestinal fermentations are perhaps the most im- 
portant exciting causes of headaches during childhood. 
Headaches of this character are commonly located in the 
front or top of the head, and are frequently associated 
with rise in temperature and other symptoms of gastro- 
intestinal fermentations, such as nausea, vomiting, flatu- 
lency, diarrhoea, constipation, and coated tongue. They 
are, as a rule, acute, especially in younger children. They 
may, however, in older children assume a chronic charac- 
ter, continuing from day to day so long as the chronic 
intestinal toxaemia exists. The relief which follows 
cathartic medication, diet, and intestinal antiseptics assists 
in the differential diagnosis of this form of headache. 

Toxic headaches are also produced by systemic bac- 
terial poisons acting on the nerve centers. This type 
of headache occurs in all the acute infectious diseases, 
and is especially severe in influenza. Headaches of this 
type are, as a rule, most severe during the invasion of 
the organism by the toxins, and therefore are among the 
early symptoms. In older children, headaches from this 
cause are more common and more severe. Headaches, 



360 NEUROTIC DISORDERS OF CHILDHOOD 

however, due to acute systemic bacterial toxaemias quickly 
declare their origin by the appearance of other signs and 
symptoms which announce the character of the infection. 

Uraemia may in the child, as in the adult, produce severe 
toxic headaches, but headaches due to this cause are noth- 
ing like so severe in the child as they are in the adult. 
Uraemic headaches are commonly located in the occipital 
region, and are associated with disturbances of vision, 
vertigo, nausea, and other symptoms of Bright's Disease. 
An examination of the urine in these cases readily differ- 
entiates this type of headache. 

Neuralgic headaches are commonly toxic in origin, and 
may be produced by malaria, influenza, gout, and rheuma- 
tism. Malaria is a very common headache producer, but 
plays this role somewhat less commonly in the child than 
in the adult. Malarial headaches declare themselves by 
their periodicity, and, as a rule, by their neuralgic charac- 
ter. The diagnosis of malarial headaches may also at 
times be confirmed by the presence of the Plasmodium in 
the blood, and by other characteristic signs of malaria. 
Periodic neuralgias may also be produced by influenza. 
A favorite location for these periodic neuralgias is in the 
supra- or infra-orbital nerves, which may remain sensitive 
to touch in the interval between the neuralgic headaches. 
It must also be kept in mind that infections involving the 
antrum of Highmore, frontal sinus, and other bony cavi- 
ties of the face may produce very severe and very per- 
sistent periodic neuralgias of facial nerves. The periodic 
character of these neuralgias commonly leads to the mis- 
taken diagnosis of malaria or influenza, until more serious 
symptoms announce the infection of these bony cavities. 



HEADACHES 361 

It is important, therefore, in the treatment of all severe, 
persistent periodic neuralgias of the supra- or infra-orbital 
nerves or other nerves of the face to make sure that the 
bony cavities of the face are not involved. 

Auto-toxins play, in the child as in the adult, the role 
of producing the most important of all the syndromes 
in which headache is the central symptom, viz., migraine. 
A separate chapter has been devoted to this form of toxic 
headache and it will not be here discussed. 

It should be remembered that both auto and bacterial 
toxins, whether of systemic or intestinal origin, act, like 
other exciting causes, more powerfully in producing head- 
ache in nervous, anaemic, malnourished children. 

A neurotic inheritance, anaemia, general malnutrition, 
and neurasthenia may one or all be underlying causes of 
headaches which may be excited by reflex, toxic, or other 
exciting factors. The etiology of headache is, as a rule, 
complex, and a diagnosis of anaemic, neurasthenic, reflex, 
or toxic headache may, therefore, be incomplete, since, as 
a rule, more than one of these factors are operative. 

Organic Headaches. — Headache may be a symptom of 
disease of the ear or of organic intercranial disease. 
Earache due to disease in the internal ear is perhaps the 
most common form of pain in the head occurring in very 
young children. Persistent pain in the head in young 
children should always excite the suspicion of disease of 
the internal ear. These cases occur so commonly in chil- 
dren during the first year of life, before the child is old 
enough to assist in the location of the pain, that they are 
commonly overlooked unless the physician is on the look- 
out for this one great cause of headache during infancy. 



3^2 NEUROTIC DISORDERS OP CHILDHOOD 

The rarity of other forms of headache during this period 
and the frequency of this type should lead to an examina- 
tion of the ear in all young children who seem to be 
suffering from severe pain, the location of which is not 
apparent. A very young child will occasionally, by lift- 
ing the hand to the ear or by the position which it takes in 
protecting that portion of the head, direct attention to the 
location of the pain. In children old enough to declare 
the location of the pain the diagnosis is of course very 
readily made; the tenderness of the external ear and of 
the mastoid, with an examination of the internal ear, will 
determine the cause of the pain. 

Headaches due to organic disease within the cranium 
may be produced by meningeal inflammation, tumors of 
the brain due to syphilis and other causes, cerebral ab- 
scess, and traumatic lesions. Headaches, however, of this 
character can scarcely be mistaken for non-organic head- 
aches. They are more severe, persistent, and localized, 
and are accompanied by other signs of the organic disease 
of which they are a symptom. 

TREATMENT 

The successful treatment of headaches comprehends, of 
course, the differential diagnosis of the various etiologi- 
cal factors and their relative importance. A search 
should first be made for reflex factors, with special refer- 
ence to eye-strain. Such reflex factors as may be found 
should, if possible, be removed. Attention should next be 
directed to the gastro-intestinal canal. It is good prac- 
tice to begin the treatment of all kinds of headache in 
children with some form of cathartic medication, such 



HEADACHES 363 

as calomel, followed by castor-oil. This will clear out the 
intestinal canal and assist very materially in determining 
the importance of the role which gastro-intestinal factors 
play in producing the headache. If the results of this 
treatment and the character of the headaches and other 
symptoms justify the diagnosis of toxic headache of in- 
testinal origin, then the further treatment will consist in 
such diet and medication as will remove the exciting 
cause. If, however, the headaches are produced by some 
acute systemic bacterial toxaemia, they may be relieved by 
cathartic medication, cold to the head, and the specific 
treatment of the acute infection of which they are the 
symptoms. In these acute conditions one is justified in 
using sedative medication to relieve the pain in the head. 
For this purpose the bromides of strontium, sodium, and 
potash, put up in essence of pepsin or some other pala- 
table vehicle, are especially serviceable. Citrate of 
caffeine in one-grain doses every hour or two, until the 
headache is relieved, is also a valuable remedy; the caf- 
feine may be combined with phenacetin or antipyrin in 
doses suited to the age of the child. My own experience 
teaches me that children bear these coal-tar products very 
well, and I have never seen any ill effects from their judi- 
cious use in the treatment of headache in children when 
the headache was dependent upon an acute systemic in- 
toxication, and I have seen very good results from their 
judicious use in the treatment of the headaches of in- 
fluenza and other acute infections. The coal-tar prod- 
ucts, however, are not to be recommended in the treat- 
ment of headaches due to chronic systemic intoxications 
(see "Migraine"). 



3^4 NEUROTIC DISORDERS OF CHILDHOOD 

The treatment of toxic headaches, whatever may be 
the origin of the toxins, also comprehends a depurative or 
eliminative treatment. This is accomplished by elimina- 
tion through the intestinal canal by the use of proper 
cathartics, preferably saline in character, and by warm 
baths to facilitate the action of the skin. When high 
temperature accompanies a headache, an ice-bag to the 
head and cold bathing to reduce the body temperature 
will at times act specifically in the relief of the headache. 

When the exciting cause of the headache is some emo- 
tional or nervous excitement brought on by fear, anger, 
or nervous shock, or when the headache is associated with 
extreme nervous irritability or other hysterical or neuras- 
thenic symptoms, cold applications to the head and good- 
sized doses of bromides act kindly in its relief. Peri- 
odic headaches of malarial, influenzal, or other origin are 
to be treated by iron, arsenic, and quinine. The following 
is an excellent formula : 

Quininae sulph. . . . -., v -.- ... «, .., ..; . 30 grains 

Ferri reducti . . . 30 " 

Acid arseniousi i grain 

M. — Make capsules No. 20. 

S. — One after eating, for a child eight to ten years of age. 

This formula is almost a specific in periodic neuralgic 
headaches, and is also of value in all forms of anaemic 
headaches. The salicylates are also valuable in the treat- 
ment of neuralgic and neuritic headaches. 

It should be remembered, however, that after all re- 
flex factors have been removed, and all sources of intoxi- 
cation looked after, there may yet remain to be considered 



HEADACHES 365 

and treated the neurotic condition which is the underly- 
ing cause of the headache. In some cases it is true this 
factor is happily absent, and the removal of the exciting 
cause, toxic or reflex, establishes a cure; but in most in- 
stances even after these factors have been removed there 
remain to be treated the constitutional causes of the 
general nervous irritability which underlie these head- 
aches. It is not, however, within the scope of this chap- 
ter to discuss the treatment of these conditions. This 
treatment comprehends not only proper hygiene, suitable 
and wholesome food, and well-directed medication, but 
also the intelligent direction of the whole life of the child, 
so that he may be properly nourished, his constitutional 
and local diseases eradicated, and his nervous system so 
protected that it may recover its normal tone and powers 
of resistance. Chronic headache not organic and not 
wholly dependent upon removable exciting factors indi- 
cates some more or less profound nutritional disturbance 
of the nerve centers, and should therefore be the warning 
sign to direct the physician's attention to the disorder of 
which it is a symptom. 



CHAPTER XXIII 

ASTHMA 

Asthma is a bronchial neurosis characterized by re- 
current attacks of spasmodic dyspnoea or sibilant bron- 
chitis without fever, but associated with or followed by 
discharge .of mucus from the bronchial tubes. 

PATHOLOGY 

The pathology of asthma is not definitely known. It 
is believed to be a neurosis which has as its underlying 
factors an instability or irritability of the nuclei or gan- 
glia which control the pulmonary branches of the pneu- 
mogastric and sympathetic nerves. The readiness with 
which these nervous mechanisms respond to irritants, re- 
flex and toxic, in certain individuals constitutes the 
asthmatic tendency or predisposition. In such individuals 
comparatively slight exciting causes, acting through the 
pneumogastric, may produce a spasmodic contraction of 
the muscular fibers of the smaller bronchi, or, acting 
through the sympathetic, may produce a vasomotor tur- 
gescence of the mucous membranes of these same bronchi, 
and thus so reduce the lumen of the small bronchial tubes 
as to seriously interfere with the intake of air, and pro- 
duce an attack of bronchial asthma. 

For a number of years the medical profession has very 
generally accepted the theory that a large proportion of 

366 



ASTHMA 367 

the cases of asthma was produced by direct (toxic) or 
indirect (reflex) stimulation of the nuclei of the pneu- 
mogastric or its terminal fibers distributed to the unstriped 
muscular fibers of the smaller bronchi. Brodie and 
Dixon have recently furnished convincing experimental 
evidence that a narrowing of the lumen of bronchial 
tubes and dyspnoea may be produced in this way. They 
found that direct stimulation of the pulmonary pneu- 
mogastric and reflex stimulation of the same fibers, pro- 
duced by irritating the nasal mucous membrane, would 
constrict the small bronchi and diminish the intake of air 
into the lungs, thus confirming the observations of Laza- 
rus, made eleven years before, that electrical stimula- 
tion of the nasal mucous membrane would produce a con- 
traction of the small bronchial tubes. These researches 
confirmed the observations of clinicians that diseases of the 
naso-pharynx may be important factors in producing 
attacks of asthma, and demonstrated the important role 
that reflex factors may play in this disease. Brodie and 
Dixon also demonstrated that certain drugs (toxins), 
such as pilocarpine, muscarine, digitalin, and carbon diox- 
ide gas, will diminish the intake of air by contracting the 
bronchi, and these experiments sustain the generally 
accepted view that certain toxins may produce asthma by 
their action on the pulmonary pneumogastric. These same 
observers found that certain drugs, such as atropin, 
hyocin, lobelia, and morphia, relieve asthmatic attacks, 
either by stimulating the broncho-dilator fibers of the 
pneumogastric or by paralyzing the bronchial endings 
of this nerve. 

Another important group of spasmodic asthmas is pro- 



368 NEUROTIC DISORDERS OF CHILDHOOD 

duced by irritations (toxic and possibly reflex) of the 
pulmonary sympathetic. In these cases the lumens of the 
bronchial tubes are diminished by congestions and swell- 
ings of the bronchial mucous membranes, and these 
swellings are probably due to a vasomotor paresis. 

Hay-fever asthma is an example of this type of asthma. 
Of this condition Osier says that he fully agrees with the 
statement of Sir Andrew Clark, that "if the structural 
changes occurring in the nasal mucous membrane during 
an attack of hay-fever were to occur also in the various 
parts of the bronchial mucosa, their presence there 
would form a complete and adequate explanation of 
the facts observed during a paroxysm of bronchial 
asthma." 

In susceptible individuals, not only the pollen of plants, 
but irritating vapors, dust, and peculiar odors, by their 
contact with the nasal mucous membrane, may excite an 
attack of asthma. In some instances these attacks seem 
to be excited by a toxin (pollen) to which the patient is 
especially susceptible, and in others reflex irritation seems 
to be the exciting cause. 

Attacks of asthma due to vasomotor turgescence of the 
bronchial tubes may also be produced by certain auto or 
intestinal toxins to which the individual patients are pe- 
culiarly susceptible. These include the cases of so-called 
urticaria of the bronchial mucous membrane. In such in- 
dividuals there is a peculiar idiosyncrasy or susceptibility 
of the pulmonary vasomotor system which makes it re- 
spond, in an asthmatic attack, to the unknown auto and 
intestinal toxins which commonly find expression in urti- 
caria of the skin. 



ASTHMA 369 

The above outline of pathological factors is believed to 
present a rational explanation of the syndrome of asthma, 
and from this outline it is evident that the term asthma, 
as here used, includes at least two distinct pathological 
conditions, the one finding expression in a functional dis- 
turbance of the pulmonary pneumogastric nerves and the 
other in a functional disturbance of the pulmonary sympa- 
thetic nerves. It is also evident from this outline that the 
etiological factors of asthma may act, in the first place, by 
producing the instability of these nervous mechanisms 
which constitute the susceptibility to asthmatic attacks, 
and, in the second place, they may act as exciting factors. 
The exciting factors include inflammatory, reflex and 
toxic causes, which act upon the mucous membranes of 
the nose and pharynx; local inflammations which act 
upon the terminal filaments of the pneumogastric and 
sympathetic nerves in the bronchial mucous membranes, 
and auto and intestinal toxins which act upon the nuclei 
of the pneumogastric, or the ganglia of the sympathetic 
nerves, or perhaps directly upon their terminal filaments 
in the bronchial tubes. 

ETIOLOGY 

Predisposing Factors. — Age. — Asthma may occur at 
any period of life. My own experience leads me to be- 
lieve that during infancy and early childhood sibilant 
bronchitis, which may be classed as a mild asthmatic mani- 
festation, is quite common, but that typical attacks of 
spasmodic asthma are comparatively infrequent. In 
older children, however, between the ages of six and 
twelve years, the adult type is very commonly seen. 



37° NEUROTIC DISORDERS OF CHILDHOOD 

Sex, — In childhood there is the same preponderance of 
males over females that occurs in later life. 

Heredity. — An hereditary neurotic constitution is be- 
lieved by all writers to be an important factor in a ma- 
jority of the cases of spasmodic asthma. There is not 
uncommonly a family history of asthma, and there is al- 
most always present a neurotic family history of some 
kind. These patients very commonly inherit a gouty, 
rheumatic, or migrainous diathesis, predisposing them to 
attacks of auto-intoxications and indirectly to attacks of 
asthma. 

Rachitis and diseases of the gastro-intestinal canal and 
other chronic anaemia producers may, by causing a mal- 
nutrition of nerve centers, increase, the predisposition of 
the individual patient to asthmatic attacks. 

Exciting Factors. — Auto-toxins of the gouty or lithae- 
mic diathesis play a not unimportant role in the etiology 
of asthma. The toxins in these cases are closely related 
to or identical with those which produce migraine and 
recurrent vomiting. Jules Comby classes among the re- 
spiratory manifestations of lithaemia in childhood spas- 
modic coryza, sibilant bronchitis, and asthmatic attacks. 
The close relationship of these syndromes is evident, and 
it is also clear that the same poisons, acting through dif- 
ferent parts of the pulmonary vasomotor nervous system, 
may produce either coryza, sibilant bronchitis, or asthma. 
This type of bronchial asthma may have among its 
etiological factors constipation, excessive eating, and an 
inactive indoor life. 

The auto and intestinal toxins which sometimes find 
expression in an urticaria of the skin may excite 



ASTHMA 371 

asthmatic attacks. F. A. Packard, in a paper on urti- 
caria of mucous membranes, called attention to the fact 
that sharp attacks of asthma and sibilant bronchitis may- 
be due to urticaria of the mucous membranes of the respir- 
atory passages. Asthmatic attacks of this character are 
preceded or followed by urticaria of the skin, and have 
the same etiological factors. 

Bronchitis, whooping cough, influenza, and measles are 
very common exciting causes of asthmatic attacks. They 
may act by irritating the nervous filaments of the pneu- 
mogastric or sympathetic nerves in the bronchial mucous 
membrane, or they may act, as does tubercular and other 
pulmonary inflammations, by enlarging the bronchial 
lymph nodes, which, by impinging on the recurrent laryn- 
geal nerve, may reflexly excite an attack of asthma. 

Diseases of the naso-pharynx, such as enlarged tonsils, 
adenoids, and hypertrophied turbinated bones, may be re- 
flex factors of sufficient importance to excite asthmatic 
attacks in especially susceptible individuals. 

The pollen toxin may be the exciting cause in hay-fever 
patients. In other specially susceptible individuals at- 
tacks of asthma are sometimes produced by a great 
variety of comparatively simple exciting causes, such as 
an overloaded stomach, intestinal indigestion, fright, or 
emotional excitement of any kind, dust, irritating vapors, 
emanations from animals, as the dog, horse or cat; the 
aroma of certain medicines, and the odor of certain 
flowers. Atmospheric and climatic conditions are im- 
portant exciting factors in a large percentage of cases; 
peculiar localities may excite the disease in one individual 
and not in another. 



372 NEUROTIC DISORDERS OF CHILDHOOD 

SYMPTOMS 

Asthma is an afebrile condition. The bronchitis or 
influenza, however, which is present as the exciting fac- 
tor may produce an elevation of temperature, but the fever 
itself does not belong to the syndrome of asthma. 

Asthmatic attacks resembling the adult type of this 
disease may occur at any age, but they are much more 
common in older children. They recur at irregular in- 
tervals, weeks or months intervening. When the 
paroxysm is on, severe attacks of dyspnoea may recur 
nightly for a time, or in other instances the dyspnoea may 
continue with marked severity for twenty-four or thirty- 
six hours, and then gradually subside into convalescence. 
Typical attacks of asthma, as a rule, come on rather sud- 
denly. They usually begin at night with a wheezing 
respiration, which soon becomes a marked dyspnoea. 
The child sits up in bed, fixing his shoulders or arms so as 
to bring all of the accessory muscles of inspiration into 
play in the attempt to force air into the already distended 
air vesicles. This increases the emphysema which ac- 
companies these paroxysms, and gives a barrel-shaped 
appearance to the chest in the latter stages of the attack. 
Expiration is prolonged and accompanied by sonorous 
and wheezing rales, and the vesicular murmur is ofttimes 
scarcely discernible. After a number of hours the dysp- 
noea gradually subsides, and is, as a rule, followed by a 
cough, with more or less mucous expectoration. The 
cough and mucous expectoration, accompanied by wheez- 
ing and large moist rales, may continue for a few hours 
or days, and then subside into rapid convalescence. 



ASTHMA 373 

In infants and younger children afebrile sibilant bron- 
chitis with slight dyspnoea is much more common than the 
typical asthmatic paroxysm above described. The dysp- 
noea in this condition is not very great. The number of 
respirations, however, is markedly increased and sibilant, 
and wheezy bronchial sounds occur, and in some instances 
persist for five or six weeks. There is no pain and com- 
paratively little discomfort — these patients often go 
about the house and amuse themselves without complain- 
ing of feeling ill. 

Holt calls attention to another type of asthma whicK 
occurs in infants and resembles capillary bronchitis. He 
says: "These cases are rare, but may be seen even in 
infants. The onset is sudden, with moderate fever, in- 
cessant cough, severe dyspnoea, and sometimes symptoms 
of suffocation . . . cyanosis, prostration, and cold 
extremities. The chest is filled with sonorous, sibi- 
lant, and soon with subcrepitant rales. Instead of run- 
ning the usual course of bronchitis of the finer tubes, the 
symptoms may pass away very rapidly, and in forty-eight, 
and sometimes in twenty-four hours, the patient may be 
quite well. It is only by the course of the disease, and by 
recurring attacks, that their true nature can be recognized. 
In infants this form of asthma may be fatal." 

LaFetra calls special attention to the eosinophilia which* 
occurs in asthma. He says : " The leucocytes are 
usually, but not always, increased, as in bronchitis ; but a 
differential count of the white cells shows what does not 
occur in bronchitis: a constant and usually marked in- 
crease in the number of poly-eosinophiles. The cases 
examined for me at the Vanderbilt Clinic by Dr. Ira 



374 NEUROTIC DISORDERS OF CHILDHOOD 

Wile showed an eosinophilia from 6 to 18 per cent. 
Cabot reports, in adults, a mean eosinophilia of 7 per 
cent., in a range from o to 53.6 per cent. This 
eosinophil is greatest for any given patient at the 
height of the attack. It disappears in the interval, but in 
sub-acute cases a low grade of eosinophilia exists. Thus 
the differential count of the leucocytes is of diagnostic and 
prognostic value, so far as the attack is concerned." This 
eosinophilia, LaFetra thinks, indicates the toxic origin of 
the disease. 

PROGNOSIS 

Patients rarely die of asthma, and the prognosis, so far 
as recovery from the asthmatic constitution or suscepti- 
bility to these attacks, is also good, provided these patients 
are so situated that they can take advantage of the means 
that are offered for the cure of this condition. To ac- 
complish a cure, however, years of careful medical super- 
vision are, as a rule, necessary. Chronic cases, however, 
which have gone on to the development of a chronic 
emphysema, do not yield readily to any form of treat- 
ment. 

TREATMENT 

Treatment of the Attack. — Inhalation of the fumes of 
stramonium leaves and niter paper may relieve the 
paroxysm ; if these fail, chloroform by inhalation will tem- 
porarily arrest the attack. In severe cases, especially in 
older children, a hypodermic of one-tenth of a grain of 
morphine may be given ; this remedy acts specifically in 
cutting short the paroxysm. Atropin, 1-1000 of a grain, 
combined with nitroglycerin, 1-200 of a grain, may be 



ASTHMA '375 

given hypodermically for the control of the paroxysm, 
and, if necessary, this dose may be repeated in two or 
three hours. An emetic will sometimes cut short a 
paroxysm of asthma, even when the gastric contents have 
little to do with exciting the paroxysm; syrup of ipecac 
may therefore be given for this purpose. Tincture of 
belladonna combined with bromide of potash, chloral, or 
antipyrin, in doses suited to the age of the child, are 
valuable remedies for modifying, shortening, and espe- 
cially for preventing, the development of an impending 
attack. 

Asthmatic attacks due to vasomotor turgescence of the 
bronchial mucous membrane are best cut short by local 
applications, by means of an atomizer to the respiratory 
passages of a solution of cocaine and adrenalin chloride. 
The 1- 1000 solution of adrenalin chloride may also be 
used in one to three minim doses in deep hypodermic in- 
jections. These remedies at times act specifically in con- 
trolling this type of asthma. 

The Interval Treatment. — The nose and throat should 
be carefully examined for causes of reflex or toxic irri- 
tation, and all such factors carefully removed. Ade- 
noids, large tonsils, nasal hypertrophies, and all diseases 
of the rhinopharynx should receive appropriate treat- 
ment. 

Bronchitis, whooping cough, measles, influenza, and 
all diseases which produce catarrh of the bronchial mucous 
membrane should be studiously avoided, or if present 
should be carefully treated until all bronchial irritation 
has disappeared. 

If the patient has a well-marked lithaemic history, the 



376 NEUROTIC DISORDERS OF CHILDHOOD 

treatment in the interval should be similar to that recom- 
mended in the chapter on Migraine. If no such history 
exists, or if the patient fail to respond to this treatment, 
then careful attention should be given to general hygiene, 
with reference to removing such nutritional disturbances 
as may possibly be predisposing factors of this neurosis. 
Iodide of potassium and syrup of hydriodic acid are 
valuable remedies in these cases, and by many writers are 
believed to exercise a specific influence in preventing 
asthmatic attacks. These remedies, therefore, should 
always be given a trial, unless some other line of tonic 
medication looking to the correction of some special 
nutritional disturbance is indicated. Cod-liver oil, iron, 
and arsenic are of value in many of these cases, and if 
there be any suspicion of malaria, quinine may be given. 

Patients suffering from asthmatic attacks associated 
with urticaria of the skin are to be treated for the 
urticaria. In such cases a preliminary cathartic of calo- 
mel and soda is to be followed every day for a week or 
more by a dose of phosphate of soda of sufficient size to 
keep the bowels thoroughly evacuated. It is advisable 
also to give these patients, for a number of days following 
the attack, either benzoate of soda or bicarbonate of 
potash in some such palatable vehicle as essence of pep- 
sin. The interval treatment of these cases is largely die- 
tetic, and consists in avoiding such articles of diet as are 
commonly believed to be responsible for urticaria, or, 
more specifically, the particular food which, in an in- 
dividual patient, seems etiologically related to these 
attacks. 

Change of climate or change of locality is after all 



ASTHMA 377 

the most important factor in the cure of these cases ; but 
in this respect it is difficult to lay down rules, since 
asthmatic patients, above all others, have the strongest 
idiosyncrasies with reference to certain localities and cer- 
tain climates. A climate or locality that may benefit one 
individual may fail to give relief to another. These 
patients, as a rule, however, do well in high and dry alti- 
tudes, unless they have chronic emphysema. Experience 
alone will determine the best locality for the individual 
asthmatic patient. It is a good rule, however, to avoid 
the locality in which the attack developed, especially at 
the season of the year when attacks are liable to occur. 
If the attack has developed in the city, a change to the 
country is advisable. If the attacks are worse in winter, 
or if they are precipitated by recurring attacks of bron- 
chitis, it is advisable to spend the disagreeable months of 
the year in some such climate as that of Southern Cali- 
fornia or Florida. 






CHAPTER XXIV 

DISORDERS OF SLEEP 

Sleep is the physiological rest which the tired organism 
demands to repair the fatigue changes incident to the 
physiological activity of cells, especially those of the nerv- 
ous and muscular systems. The physiological activity 
of all the organs of the body alternates with periods of 
relative repose. This repose is absolutely necessary to 
the vital activity of cells. In the higher animals the cen- 
tral nervous system rests at least once in twenty-four 
hours, and this condition of rest is called sleep. Normal 
sleep is characterized by loss of consciousness, loss of 
voluntary inhibitory control of motor and mental acts, 
and more or less complete loss of all the special senses. 
Sight goes first, probably taste and smell next, and finally 
touch and hearing disappear as sleep becomes profound. 
During sleep all of the higher functions of the brain are 
held more or less in abeyance, and the involuntary inhibi- 
tory control of motor and mental acts is also partially lost. 
The discharge of nervous stimuli to all the organs of the 
body is greatly diminished, and as a result there is more 
or less relaxation of the muscular system, and a feebler 
functional activity of nearly all the important glands. 

During sleep, however, the capacity of the central nerv- 
ous system to react to peripheral stimuli is not alto- 
gether lost. But the more profound the sleep the stronger 
must the peripheral stimulation be to make any impression 

378 






DISORDERS OF SLEEP 379 

upon the nerve centers. In the very beginning of sleep 
the nervous system may respond very actively to slight 
external stimuli, producing muscular twitchings of , the 
body, which may be severe enough to arouse the individ- 
ual with the knowledge that this spasmodic contraction 
has occurred. These phenomena, however, are more 
likely to occur in highly nervous individuals, the nervous- 
ness being produced by unusual activity of the brain be- 
fore going to bed, or by an excitable condition of the 
higher nerve centers produced by toxins. While this 
condition of increased reflex excitability at the beginning 
of sleep can scarcely be said to be physiological, yet it is 
made possible by the fact that the higher nerve centers, 
which exercise inhibitory control over the lower, are the 
first to lose their functions under the influence of sleep; 
and as sleep becomes more and more profound the entire 
nervous system gradually sinks into a condition of more 
or less complete repose, the motor centers at the base of 
the brain and the reflex centers of the cord being the last 
to come under its sedative influence. When the entire 
nervous system has come under the influence of profound 
sleep, the reflex centers of the brain and cord are not so 
readily excited to action by peripheral stimuli as they are 
in the beginning of sleep, when the inhibitory centers are 
in repose, and the motor centers have not yet lost their 
normal excitability. During the first hour sleep becomes 
more and more profound. At the end of this time the 
higher nerve centers are very profoundly under its in- 
fluence, and it requires comparatively powerful stimuli to 
bring the individual back to consciousness. During the 
second hour sleep becomes gradually less profound, and 



38O NEUROTIC DISORDERS OF CHILDHOOD 

from this time on a comparatively slight stimulus is suffi- 
cient to awaken the individual. The profound sleep of 
the first two hours has been likened to a condition of nar- 
cotism, which slowly passes off, leaving the individual 
still unconscious, but easily aroused. The lower motor 
centers of the brain and spinal cord maintain about the 
same degree of irritability from the beginning to the close 
of sleep. They are apparently not influenced, as the 
higher centers are, by the narcotism of the first and second 
hours of sleep. 

The healthy new-born infant sleeps nearly all of the 
time, at least twenty out of the twenty-four hours. Dur- 
ing the first month the normal infant is awake about four 
hours in the twenty-four. From this time on the child 
requires slightly less sleep, so that at six or eight months 
he is sleeping sixteen hours in the twenty-four, and at 
the age of one year he sleeps from twelve to fourteen 
hours. During the first few days of life sleep is heavy, 
owing to the fact that the organs for receiving and carry- 
ing peripheral stimuli to the central nervous system are 
not yet fully developed. From this time on during the 
next month sleep becomes less profound, and from the 
end of the third month to the end of the second year sleep 
is not so deep as it is after the third or fourth year, when 
the heavy sleep of childhood is seen. It is at this time in 
the life of the individual that the profound narcotism of 
the early hours of sleep is most noticeable. 

The most common disorders of sleep are night-terrors, 
somnambulism, and insomnia. Of these the most impor- 
tant is night-terrors, or pavor nocturnis. 

Pavor Nocturnis. — Night-terrors is a neurosis depend- 



DISORDERS OF SLEEP 38 I 

ent upon an abnormally irritable nervous system, easily 
excited by reflex stimuli having their origin in distant 
parts of the body or in the cortical centers themselves. It 
is characterized by a night-terror which finds expression 
in the child's screaming or crying out in a panic of fright 
during sleep. 

ETIOLOGY 

Heredity is a very potent etiological factor. In the 
most severe cases there is commonly a well-marked neu- 
rotic family history, and such neuroses as epilepsy, hys- 
teria, chorea, migraine, and neurasthenia not uncom- 
monly occur in the family histories. This strong heredi- 
tary taint predisposes these children to reflex and con- 
vulsive neuroses of all kinds. The particular defect of 
the nervous system which is inherited is a feeble inhibi- 
tory control of mental and motor acts. This may explain 
the relationship existing between epilepsy, infantile 
eclampsia, and night-terrors which appear to be present 
in some families. Beyond this there is perhaps no direct 
connection between these neuroses. While a neurotic 
family history resulting in an extremely irritable nerv- 
ous system under feeble inhibitory control is present in 
many of the more severe cases of night-terrors, this factor 
is by no means so well marked in the milder types of this 
disorder. In some instances the excitable nervous 
system seems to be wholly dependent upon other factors 
entirely foreign to hereditary influences. 

Malnutrition is an important factor in developing irri- 
tability of the nervous system in young children, and the 
coninion causes of malnutrition, such as lymph node tuber- 



382 NEUROTIC DISORDERS OF CHILDHOOD 

culosis, chronic diseases of the gastro-intestinal tract, 
chronic malaria, hereditary syphilis, and rachitis, with 
improper food, impure air, and bad hygiene, may there- 
fore be important predisposing factors of night-terrors. 

Mental overwork and nerve excitement, when coupled 
with physical inferiority, are most potent factors in pro- 
ducing the highly excitable state of the nervous system 
which makes possible the development of this syndrome. 
School life, therefore, in a child of feeble constitution 
may, with its mental grind, increased nerve excitement, 
close confinement, and eye-strain, be a factor in the de- 
velopment of night-terrors. 

Exciting Causes, — The normal irritability of the 
nervous system of the child having been exaggerated by 
heredity, malnutrition, mental overwork, or nerve excite- 
ment, makes it possible for certain reflex exciting causes 
to develop an attack of night-terrors. The intestinal 
canal is one of the most important sources of this reflex 
irritation ; undigested food, improper food, excess of 
food, intestinal worms, and intestinal fermentations, 
with the intestinal toxins which they produce, may all 
either directly or indirectly act as exciting factors of 
night-terrors. Adenoids, enlarged tonsils, and nasal ob- 
structions that interfere with normal breathing during 
sleep may either act as reflex factors or they may act by 
producing a partial asphyxia, and thus excite an attack 
of night-terrors. 

In many cases, however, the reflex factors are absent, 
or perhaps it might be better to say are so slight that they 
cannot be readily discovered. In these cases the attack is 
apparently excited by a horrible dream, which has its 



DISORDERS OF SLEEP 383 

origin either in some alarming occurrence of the pre- 
vious day or in the overstimulation of the emotional 
centers produced by blood-curdling tales or exciting fairy 
stories just before going to bed. These cases, which are 
cerebral in origin, belong to the class previously described 
as strongly neurotic. The nervous systems of these ex- 
tremely neurotic children may be so excited by punish- 
ment, by fits of anger, and by fright that they fall asleep 
with the incidents of the day still impressed upon their 
nervous systems, and, as a result, the cortical centers do 
not come profoundly under the reposeful influences of 
sleep, and in the paroxysm of night-terrors which super- 
venes the horrible vision which presents itself to the 
child in his night-terror is but an exaggerated reflex of 
some mental impression which he received during the 
day. 

SYMPTOMS 

Silbermann divided night-terrors into two rather dis- 
tinct clinical types, which for the most part have been 
recognized by recent writers. One of these he called 
Idiopathic Night-Terrors, and the other Symptomatic 
Night-Terrors. The idiopathic type is of central or cor- 
tical origin, and the symptomatic of peripheral origin. 
In the description which follows these two types will be 
recognized. 

Central or Idiopathic Night-Terrors has for its most 
important etiological factor an extremely excitable nerv- 
ous system under feeble inhibitory control which has 
been inherited from neurotic parents. In the family his- 
tory of these cases, hysteria, neurasthenia, and the convul- 



384 NEUROTIC DISORDERS OF CHILDHOOD 

sive neuroses, all of which are largely dependent upon 
feeble inhibition, are common. The inherited neurotic 
condition in these cases may also be aggravated by mal- 
nutrition and improper training. There can be little 
doubt, however, that even in these cases peripheral irrita- 
tion plays a part in touching off the paroxysm; but the 
central nervous system is in such a state of excitability, 
and under such feeble inhibitory control, that a slight 
peripheral irritation produces a maximum result, and for 
these reasons it is commonly disregarded or overlooked. 
Idiopathic night-terrors occur in the great majority 
of instances between the ages of two and eight years. 
This is the period of life when feeble inhibitory control of 
cortical and other centers is responsible for many of the 
graver neuroses, such as eclampsia, epilepsy, and chorea. 

THE PAROXYSM 

A neurotic child, with its nervous system unusually ex- 
cited by the incidents of the day, falls asleep, and after 
an hour or two suddenly starts in its sleep with a cry of 
terror which alarms the household. A moment later he 
is found apparently wide-awake, sitting up in bed, or 
crouching on the floor in a state of wild excitement, star- 
ing and pointing at some horrible imaginary object which 
he seems to see with great distinctness. He trembles 
with fear and gesticulates wildly, calling for assistance, 
but when spoken to fails to recognize his mother or nurse, 
who are vainly endeavoring to arouse him to conscious- 
ness. He may call out the name of some man or 
animal who he thinks is about to do him injury. After 



DISORDERS OF SLEEP 385 

a few minutes of this agonizing fear the attack seems to 
spend its force, the excitement gradually passes away, and 
the little patient may fall back upon the pillow and be- 
come quiet in sleep, which may continue without further 
disturbances until morning. In many instances the child 
will go through an attack of this kind without recovering 
consciousness. In other words, the whole attack occurs 
during sleep. In other instances the strenuous efforts of 
the attendants may arouse the child to a vague conscious- 
ness, or, rather, semi-consciousness, during which, in a 
dazed way, he recognizes his surroundings, and then 
quickly drops asleep, and the next morning has little 
or no recollection of what has occurred during the night. 
According to Silbermann, Coutts, and other observers, 
the seeing of visions is the most characteristic feature of 
these attacks of central or idiopathic night-terrors. In 
this condition similar attacks may occur for a number of 
nights in succession, or there may be an interval of weeks 
or months between them, but they always present very 
much the same clinical picture, although they vary in in- 
tensity. 

Incontinence of urine may occur during these attacks, 
or the child may at the close of the attack make known 
his wants, and after seeking the commode pass urine or 
have a movement from the bowels, as though he were en- 
tirely conscious of his actions, and yet give no other evi- 
dence of being conscious of his surroundings, returning 
to bed and continuing his sleep, and the next morning 
having no recollection of these occurrences. 

This central type of night-terrors is believed by many 
writers to be closely related to epilepsy, and quite a num- 



386 NEUROTIC DISORDERS OF CHILDHOOD 

ber of cases of epilepsy have been reported in which night- 
terrors occurred as a part of their early history. Concern- 
ing this relationship, however, I am quite in accord with 
the opinion expressed by Charles Putnam in his excellent 
paper on this subject in the " Cyclopedia of the Diseases 
of Children." He says : " Altogether, the connection 
between night-terrors and epilepsy, in so far as they are 
separate diseases, is no clearer than that between any two 
of the neuroses, and yet, inasmuch as attacks closely re- 
sembling night-terrors are occasionally only symptoms of 
epilepsy, it is well to watch carefully for a time before de- 
ciding that epilepsy is not present." 

Symptomatic Night-Terrors are more common in child- 
hood, but they may occur at any age. This type is much 
more common than idiopathic night-terrors. In sympto- 
matic and peripheral night-terrors the essential etiological 
factor is outside the nervous system in some peripheral 
excitation. Children suffering from this symptom-com- 
plex have, as a rule, unstable and irritable nervous sys- 
tems, but this nervous instability, instead of being heredi- 
tary, is, as a rule, acquired. Chronic malnutrition and 
other factors capable of producing an unstable nervous 
system in an otherwise healthy child may commonly be 
observed. The reflex factors above noted as having 
their origin in the intestinal canal, nose, throat, and other 
organs are present, and can, as a rule, be very readily 
discovered. 

The Paroxysm.— -The child falls asleep and may toss 
restlessly for an hour or two before the reflex irritation 
to the nervous centers culminates in an attack of night- 
terrors. The patient screams with terror, sits up in bed, 



DISORDERS OF SLEEP 387 

or runs about the room. He is wildly excited, trembles 
with fear, and exhibits a very marked but as a rule un- 
defined terror. He sees no visions and hears no noises, 
and responds to the efforts of his attendants to arouse 
him. He recognizes his attendants and seeks consolation 
from them. His nervous fears, however, are soon 
quieted, and he falls asleep to awaken the next morning 
with perhaps a vague recollection of the occurrences of 
the night. 

Silbermann, and after him Coutts, have called atten- 
tion to the differences in the clinical pictures portrayed in 
the two types of night-terrors. Coutts uses the term 
night-mare to describe the class of cases which Silber- 
mann speaks of as symptomatic or peripheral. As 
Coutts puts it, the chief distinction between these two 
symptom groups is that the one suffering from idiopathic 
night-terrors " sees visions," while the one suffering 
from symptomatic night-terrors merely " dreams 
dreams." Silbermann expresses the same idea by say- 
ing that the former is characterized by objective terror 
and the latter by subjective terror. It may be added also 
that in the idiopathic form the terror is more real, the 
mental excitement greater, and the condition of uncon- 
sciousness more profound. 

Notwithstanding the differences in the clinical pictures 
which the two types of night-terrors present, I am not 
prepared to say that they are distinct clinical entities. I 
am rather inclined to believe that the idiopathic type of 
this disorder presents the aggravated clinical picture as 
it may occur in highly neurotic children whose mental 
and motor mechanisms are under feeble inhibitory con- 



388 NEUROTIC DISORDERS OF CHILDHOOD 

trol. Between this extreme type and the milder attacks 
of symptomatic night-terrors, due almost wholly to strong 
reflex excitation of an almost normal nervous system, 
there is indeed a wide difference in the clinical pictures 
presented, but certainly not more so than there is in 
epilepsy or other neuroses. In this regard I quite agree 
with Putnam, who says : " It is hard to convince one's 
self that there are two classes so definitely separated from 
each other. It is true that between two individual cases 
there may be a vast difference in all the particulars men- 
tioned by Silbermann, but taking all cases together, the 
degrees of difference are so slight that it is almost, or 
quite impossible, to draw a line of demarkation." 

PROGNOSIS 

In the symptomatic form the prognosis is very good, 
because it is produced by etiological factors which can 
readily be removed by appropriate treatment. In the 
idiopathic form the prognosis is not so good, and depends 
largely upon the gravity of the underlying hereditary 
taint. All of these cases, however, should yield to ap- 
propriate treatment, but idiopathic night-terrors should 
call attention to, and demand treatment for, the under- 
lying hereditary condition. 

TREATMENT 

In beginning the treatment of all of these cases the in- 
testinal canal must be carefully scrutinized and all pos- 
sible reflex irritation from this source removed. . A pre- 
liminary cathartic followed by a carefully regulated diet 



ttfSORDERS OF SLEEP 389 

with a light evening meal should be a part of the treat- 
ment in every case. It is impossible to lay too much stress 
upon the role which disorders of the gastro-intestinal 
canal play in these cases. It is incumbent upon the 
physician, therefore, to thoroughly satisfy himself that 
the intestinal canal of the child is no longer a source of 
irritation or intoxication to the nervous system, and in 
doing this he must remember that severe intestinal toxae- 
mia may be present without any pronounced symptoms 
on the part of the gastro-intestinal tract. Enlarged ton- 
sils, adenoids, and nasal obstructions of all kinds, as well 
as all other discoverable causes of reflex irritation, should 
be removed. 

The child's general health should be carefully looked 
after. A diet should be selected with reference to the 
character of the malnutrition present. Tonics, such as 
iron, arsenic, cod-liver oil, or a malt containing diastase, 
may be indicated in individual cases. An outdoor life, 
with an abundance of sunshine and fresh air, is also 
important. With all these measures, looking towards 
the removal of reflex irritation and the underlying con- 
stitutional factors, must be combined careful protection 
of the nervous system. In the idiopathic cases the 
child's nervous system should be as carefully shielded 
from mental strain and nerve excitement, as if she were 
suffering from one of the graver neuroses. The medical 
treatment of these cases consists in giving the bromides 
of strontium, or potassium, in five- or ten-grain doses at 
bedtime. It is best to combine with this a dose of 
tincture of belladonna suitable to the age of the child 
(one to four minims). The bromide of potash and Delia- 



39° NEUROTIC DISORDERS OF CHILDHOOD 

donna will, as a rule, readily control the paroxysms, and 
after four or five nights all sedative medication may 
cease. In some cases, however, it is necessary to give 
this prescription for weeks at a time for the control of 
paroxysms in the severe cases. It is best, however, to 
discontinue all sedative medication as soon as the 
paroxysms are controlled. 

INSOMNIA 

Prolonged insomnia, as it occurs in the adult, lasting 
through the greater portion of the night, is uncommon 
in children, and when it does occur is a symptom of some 
more or less serious disease. 

Disturbed or unrefreshing sleep, with possibly a few 
hours of wakefulness, is common in childhood, and it is 
this condition rather than true insomnia which here 
interests us. 

ETIOLOGY 

Disturbed sleep is produced by very much the same 
etiological factors as night-terrors. A general nervous 
irritability is probably the most important underlying 
factor, and this irritable condition of the nervous system 
may be a matter of heredity, or it may be produced by 
chronic malnutrition, or it may occur in the convales- 
cence from acute infections. This irritable condition of 
the nervous system may be very greatly exaggerated by 
more or less constant nerve excitement. The mental 
stimulation and strain of school life, with night study 
and the anxiety which sensitive children have concerning 
the lessons of the following day, may in older children 



DISORDERS OF SLEEP 39 1 

be causes of disturbed sleep. In infancy nervous ex- 
citement is also a cause of restless sleep. The habit of 
constantly entertaining infants, and constantly attract- 
ing their attention, and bringing them into the whirl 
and excitement of the living-room, where they may be 
observed and commented upon, cannot be too severely 
condemned. Filling young minds with exciting stories 
before they are put to bed predisposes to dreams and 
disturbed sleep. 

Lack of proper training is, in the young infant, the 
most potent of all causes of insomnia. Rocking infants 
to sleep and lifting and fondling them every time they 
make an outcry, with feeding at night, will bring about 
the habit of insomnia and disturbed sleep. 

Disturbances of digestion are the most important of 
the direct exciting causes of insomnia. Over-feeding 
and improper feeding may develop in the intestinal 
canal important reflex and toxic factors which, by their 
action on the nervous system, may disturb sleep. In 
infants intestinal fermentation may, by the development 
of gases, produce colic. This may also occur in older 
children, but as a rule constipation, with a more or less 
obscure intestinal toxaemia, is with them a more im- 
portant factor of nocturnal restlessness. In very young 
infants hunger may be a cause of sleeplessness. 

Poorly ventilated and overheated rooms, with lack of 
fresh air, heavy and uncomfortable bed-clothing, denti- 
tion, otitis, adenoids, enlarged tonsils, and nasal obstruc- 
tions, may cause restlessness at night. 

As a rule, more than one of the above-named factors 
are present in the production of insomnia, and individual 



39 2 NEUROTIC DISORDERS OP CHILDHOOD 

cases must be carefully studied, with all of these possible 
factors in mind, in order to ferret out the responsible 
factors in any given case. 

TREATMENT 

The prophylactic treatment, which should begin when 
the child is born, is of the utmost importance. This 
consists in carefully regulating the life of the infant, 
shielding it from excitement, feeding it at regular in- 
tervals, and insisting from the beginning that the night 
shall be devoted to sleep. It is a comparatively simple 
matter to establish a routine regularity which will firmly 
engraft upon the infant the habit of sleeping profoundly 
throughout the night. This habit, when once established 
and closely adhered to, will do much to overcome the 
nervous irritability which the infant may have inherited. 
As the child grows older this regularity in eating and 
sleeping should be carefully adhered to, and the child 
should be given a light evening meal and put to bed soon 
afterward. 

Treatment of the Condition. — When the habit of in- 
somnia is once established, the treatment consists in 
attempting to establish the regularity above referred to, 
and which a lack of proper training has interfered with. 
An effort should be made to discover the essential causes 
of the sleeplessness. Disturbances of the intestinal tract 
should be carefully treated, and all possible causes of 
reflex irritation, whether they occur in the nose, throat, 
or elsewhere, should be removed. The child should sleep 
in a well-ventilated and not overheated room, and the 
bed-clothing should be properly adjusted to the season 






DISORDERS OF SLEEP 393 

of the year. If the child suffers from cold feet, a warm 
bath at night with a hot-water bottle to the feet may 
assist in overcoming the sleeplessness. Over-pressure at 
school and mental excitement of all kinds, especially just 
before going to bed, should be avoided. 

Insomnia, occurring as an acute condition in an other- 
wise healthy infant, should lead one to suspect acute 
intestinal disturbance. Intestinal pain produced by colic, 
which is such a common cause of restless sleep, may be 
relieved by an enema. A child that has fretted and 
tossed for hours may fall asleep after this procedure. 

The use of medicines to promote sleep in children is 
rarely necessary, unless the restlessness is produced by 
some acute febrile condition. Bromide of potash and 
strontium are perhaps the most justifiable remedies 
under these conditions. Other hypnotics which are so 
valuable in the treatment of insomnia in the adult are of 
doubtful value in the child. 

SOMNAMBULISM 

Somnambulism, or sleep-walking, is a disorder of 
sleep having very much the same etiological factors as 
night-terrors and insomnia. 

The somnambulist, soundly asleep and apparently 
perfectly unconscious, with his special senses in abey- 
ance, may rise, walk, or run about in the dark, avoiding 
objects and performing difficult and apparently pur- 
posive acts quite as dexterously as he could when awake. 
When aroused from this state he is perfectly unconscious 
of what has transpired. 

Somnambulism is not uncommonly observed in chil- 



394 NEUROTIC DISORDERS OF CHILDHOOD 

dren, but the marvelously complicated movements which 
have been accredited to adult sleep-walkers have not 
been noted in the child. Children, however, may get out 
of bed and walk or run about the room in the pursuit 
of some object, or with a definite purpose suggested 
by a dream, which the child is acting. 

Sleep-talking may be combined with sleep-walking. I 
once witnessed a performance of this kind in a child 
seven years of age. This child during the day had 
been much interested in seeing his dog Towser catch 
and kill some rats as they were one by one liberated 
from a trap. In the early hours of the night he sprang 
from bed and ran in the dark through the house, calling 
to his dog, " Rats ! Towser, rats ! Towser, here they 
are ! " and for some minutes, avoiding furniture and 
directing his movements with great accuracy, he led the 
chase until he was finally captured by his mother and 
in his half-dazed state led back to bed and to sleep. The 
next morning he knew nothing of the occurrence. 

The treatment for this condition is the same as that 
above outlined for insomnia. 



CHAPTER XXV 

NYSTAGMUS AND ASSOCIATED MOVEMENTS OF THE HEAD 
IN INFANTS 

W. B. Hadden, under the title " Head-nodding and 
Head- jerking in Children, Commonly Associated with 
Nystagmus," described a not uncommon neurosis char- 
acterized by rotary, lateral, or vertical movements of the 
head, commonly associated with rotary, lateral, or 
vertical movements of the eyes. 

CHARACTER OF THE MOVEMENTS 

Peterson described, under the term " gyrospasms," a 
rotary movement of the head from right to left and left 
to right. These head movements may also take the form 
of " head-nodding " ; in these cases the head moves with 
a vertical nodding motion. In other cases the move- 
ments of the head are horizontal. These vibratory 
movements of the head are, as a rule, rhythmical and 
rapid, two or three vibrations occurring to the second. 
The same movements, however, do not always persist. 
Any one of these movements may be replaced by or 
alternate with either of the others, or the three move- 
ments of the head — vertical, horizontal, and rotary — may 
all occur at different times in the same patient. 

Hadden says that pure nodding is rare, but this move- 
ment is commonly combined with or alternates with the 
lateral or rotary movements. 

395 



396 neurotic disorders of childhooQ 

In some cases these movements may cease when the 
child's attention is firmly fixed on some object, but as 
a rule the movements are increased when the child is 
under observation. During sleep the movements cease, 
and they are not so well marked, and commonly dis- 
appear when the child is lying down and quiet in a 
darkened room, and they may sometimes cease when the 
eyes are covered. 

Nystagmus is commonly associated with these head 
movements, and the eye movements may be rotary, ver- 
tical, or lateral. The movements of the eyes, however, 
are more rapid than the movements of the head, the 
vibrations in some instances being as rapid as six to the 
second. These involuntary vibrations of the eye are, as 
a rule, rhythmical. The horizontal movement is the 
most common, but it may alternate with or be replaced 
by vertical or rotary movements, and rarely, according 
to Mills, " the vertical and horizontal oscillations may 
alternate regularly or irregularly, or a vertical move- 
ment may be present in one eye and a horizontal in 
another. The commonest form of nystagmus is that in 
which the movement is bilateral, horizontal, and con- 
sentaneous." 

Hadden also notes that there is a " relation between 
nystagmus and the position of the eyes, or even the 
ocular state. In one case the nystagmus was exag- 
gerated on extreme conjugate deviation to the right. 
In two instances the nystagmus was chiefly evident when 
the eyes were directed upward, and in one of these it 
was generally horizontal and tended to become vertical 
when the eyes were turned upward. The nystagmus 



NYSTAGMUS AND ASSOCIATED MOVEMENTS 397 

may vary in direction apart from this; in two instances 
it was sometimes vertical, sometimes horizontal, and 
sometimes rotary." 

The movements of the head and eyes do not always 
correspond. Any form of eye movement may be com- 
bined with any form of head movement; for example, 
head-nodding may be combined with lateral nystagmus, 
or we may have nystagmus of one eye associated with 
any form of head movement. In short, any number of 
combinations of the various head movements and eye 
movements are possible, but it should be remembered 
that in perhaps a majority of cases the head and eyes 
move in the same direction. 

The various head movements above described, while 
commonly associated with nystagmus, may occur with- 
out the nystagmus, and on the other hand the nystagmus 
may occur without the head movements. Nystagmus 
is not associated with any abnormal condition of the eyes, 
although in some instances it is associated with strabis- 
mus. Head movements are sometimes associated with 
strabismus, without nystagmus. On the whole, however, 
the association between strabismus and the syndrome 
above described is not very common. 

ETIOLOGY 

This syndrome, as a rule, occurs during the first year 
of life, commonly between the second and twelfth 
months. During the second year of life it is not infre- 
quent, but after that it is very uncommon, except as it 
is associated with organic disease of the nervous system, 
insanity, or congenital idiocy. In this chapter, however. 



39$ NEUROTIC DISORDERS OF CHILDHOOD 

we are interested only in this syndrome as a manifesta- 
tion of a not-uncommon neurosis which occurs almost ex- 
clusively between the beginning of the third and the end 
of the twentieth month of life. The fact that this con- 
dition almost never occurs before the end of the second 
month and is very rare after the twentieth month is 
an evidence that the condition is a developmental one. 
Before the second month the centers which control the 
eye and head movements are not sufficiently developed 
to respond to reflex and other excitations, but after these 
centers have developed and before the eye and head 
movements are under proper inhibitory control we may 
have developed the syndrome as above described. Later, 
however, when the spinal accessory and motor oculi 
centers are under inhibitory control from cortical cen- 
ters, these movements become impossible, and this neu- 
rosis disappears. Age is, therefore, above all the great 
predisposing cause of this neurosis. 

Sex has little influence. Most writers state that the 
condition is more common in females. 

Heredity is perhaps an important predisposing factor. 
In many of the cases there is a bad neurotic family 
history, epilepsy, chorea, hysteria, and other neuroses 
which are characterized by feeble inhibition having been 
noted. 

Rachitis and gastro -intestinal disease, with improper 
food, impure air, and bad hygienic surroundings, are also 
very important predisposing causes of this neurosis. 
These are the great factors which produce malnutrition 
in infants, and the malnutrition of the nerve centers, 
which are a part of these conditions, is probably the 



NYSTAGMUS AND ASSOCIATED MOVEMENTS 399 

predisposing factor. All writers are agreed that there 
is a close association between rachitis and this neurosis, 
some believing that rachitis is almost an essential factor 
and others that it is present as an etiological factor in a 
minority of the cases only. It is not probable that there 
is any specific relation between rachitis and this neurosis ; 
if so, it would be much more common than it is. It is 
more probable that rachitis acts as a predisposing factor 
by interfering with the development of inhibitory cen- 
ters and increasing the irritability of the nerve nuclei 
involved. 

Exciting Causes. — We know little or nothing of the 
exciting causes of this condition. Peterson believed that 
trauma, or head injury of some kind, mild or severe, 
producing concussion of the brain, may be found in most 
of the cases to be the determining factor. Other writers, 
however, have not laid much stress upon trauma as an 
exciting cause. Henoch believed that dentition is an 
exciting factor; the reasons, however, for this belief are 
not very clear. It is true that some of these cases occur 
during the time of dentition, and it is also true that 
dentition in rachitic, malnourished infants may produce 
rather pronounced nervous symptoms; but there is no 
more direct evidence than this that dentition is an excit- 
ing factor of the syndrome under discussion. 

PATHOLOGY 

The pathology of this condition is largely a matter of 
speculation. Hadden expressed the opinion that this 
syndrome is produced by an instability of cortical motor 



400 NEUROTIC DISORDERS OF CHILDHOOD 

centers having control of the nuclei in the spinal cord 
and fourth ventricle. The young infant gradually ac- 
quires certain voluntary or purposive movements of the 
head and eyeballs, and these movements, not being 
thoroughly under the control of the cortical inhibitory 
centers, are not directed or restrained, and there results 
the involuntary oscillations above described. This view 
of Hadden is concurred in by Mills and other writers, 
who believe this the best explanation of a very obscure 
condition. My own view is also in accord with Had- 
den's, as I above outlined in explaining the important 
role that age plays as an etiological factor. 

PROGNOSIS 

The prognosis is, as a rule, good. This syndrome, 
however, in one or more of its manifestations may con- 
tinue for months, but under proper care recovery finally 
occurs. The head movements, as a rule, disappear 
before the nystagmus. 

In making the prognosis in an individual case it is 
important that the neuroses above described be care- 
fully differentiated from the same head and eye move- 
ments occurring in certain organic diseases of the brain, 
as well as these same movements occurring with the so- 
called imperative movements of defective children. 
These imperative movements in feeble-minded children 
very commonly take the form of a salaam, or repeated 
movements of the arm, trunk, or leg. If such move- 
ments as these are associated with the syndrome under 
discussion, the prognosis is not so good. 



NYSTAGMUS AND ASSOCIATED MOVEMENTS 401 
TREATMENT 

The treatment is largely a matter of improving the 
child's general nutrition. Rachitis and the underlying 
gastro-intestinal disease, if present, must be carefully 
treated by diet and proper medication. A carefully 
selected diet, suitable to the age and digestive capacity of 
the child, is absolutely necessary; fresh air and whole- 
some hygienic surroundings should be insisted upon. 
Cod-liver oil and some palatable and easily assimilated 
preparation of iron may be of value. Under this treat- 
ment the child's malnutrition gradually disappears, the 
nervous centers are better nourished and become less 
irritable, and the inhibitory centers of the cortex gradu- 
ally assume more perfect control of the lower centers, 
and as a result the syndrome disappears. 

Sedative treatment is also of value in beginning the 
treatment of some of these cases. Bromide of strontium, 
or some of the other bromides put up in essence of 
pepsin or some other palatable solution that will not 
disturb the stomach, may be given for the purpose of 
controlling the nervous symptoms. These bromides 
may be given in from three to five-grain doses three or 
four times in twenty-four hours, but they should be 
discontinued unless there is evidence that they are of 
decided value in the treatment of the case. 



CHAPTER XXVI 

HABIT-SPASM AND OTHER HABIT-NEUROSES 

Habit-spasm is a pure neurosis characterized by sud- 
den and quick contractions of certain groups of muscles. 
These spasmodic movements are most common in the 
muscles of the face, neck, and shoulders. 



ETIOLOGY 

This syndrome is sometimes spoken of as habit-chorea. 
This name is a misnomer, not only because it leads to 
confusion, but also because the two syndromes, chorea 
and habit-spasm, are not in any way related. The 
clinical pictures which the two conditions present are 
so different that they can scarcely be mistaken one for 
the other, and their etiological factors are not the same. 

Heredity is an important predisposing factor. These 
patients, as a rule, belong to families having strong 
neurotic tendencies, and have themselves inherited 
unstable and easily excitable nervous systems. 

Chronic auto or intestinal intoxications, or any of the 
forms of malnutrition which either irritate or mal- 
nourish the central nervous system, may be important 
predisposing factors of the habit-neuroses. 

Age. — According to Weir Mitchell this syndrome is 
most common between the ages of seven and fourteen, 

402 



HABIT-SPASM AND OTHER HABIT-NEUROSES 403 

The prevalence of the disease during this period may 
perhaps be largely explained by two important etiological 
factors which are potent at this time in the life of the 
child, viz., the development of the reproductive organs 
and school life, both of which may aggravate the 
instability of the nervous system of neurotic chil- 
dren. 

School life, in my opinion, brings to bear on the 
irritable nervous systems of neurotic children the etio- 
logical factors which are most important in the develop- 
ment of habit-spasm. The mental training, the confine- 
ment, restraint, and enforced quiet, the unhygienic sur- 
roundings, the anxiety to excel, the fear of punishment, 
and the increased eye-strain which school life entails 
may all be factors in aggravating the neurotic tendencies 
of nervous children. The precocity which is common in 
children suffering from habit-spasm may encourage a 
degree of mental training that leads to the exhaustion of 
nervous energy, and thus may produce neurotic disease 
in a rapidly growing child. Rapid growth of body is 
not to be combined with rapid mental development in 
nervous children. 

The failure to properly protect the nervous systems of 
neurotic children during the functional development of 
the reproductive organs may also lead to the develop- 
ment of habit-spasm and other neuroses. The physical 
condition of the child may also be important during this 
period of development, but general malnutrition does not 
appear to play so important a role in the development 
of this neurosis as it does in many others. 

Exciting Factors, — With the nervous system of the 



404 NEUROTIC DISORDERS OF CHILDHOOD 

child prepared by the etiological factors above noted, it 
is easy to understand how apparently unimportant 
exciting causes may play a role in developing habit- 
spasm. These factors are, of course, made potent only 
by reason of the irritable and unstable condition of the 
nervous system which has resulted from the more im- 
portant factors. Among the exciting causes, however, 
which play a role in the production of habit-spasm, 
imitation is perhaps the most powerful, and, when once 
the habit has been developed, sympathy for the child 
and attention to the spasm are very important factors 
in aggravating and continuing the spasmodic move- 
ments. 

An extremely precocious and highly neurotic little 
patient of mine, two years of age, who from the tenth 
to the eighteenth month of her life practiced the habit 
of thigh-friction, recently came in contact with a child 
who had habit-spasm of the muscles of the face. Very 
soon my little patient was noticed to have contracted the 
identical habit-spasm which the older child had. The 
spasm consisted in a drawing downward and outward of 
the left corner of the mouth with a quick, sudden con- 
traction. On seeing the child, I was able to elicit the 
spasm by talking of it or calling attention to it. For this 
reason I forbade the nurse or any member of the family 
to again notice or speak of the spasm. Under this treat- 
ment the contraction became less frequent, and after 
about ten days ceased entirely. In this case the spasm 
was controlled before the habit became fixed. 

Eye-strain, diseases of the nose, throat, and pharynx, 
and all other sources of reflex irritation should be care- 



HABIT-SPASM AND OTHER HABIT-NEUROSES 40$ 

fully searched for and removed, since such factors may 
be etiologically related to habit-spasm. 



SYMPTOMS 

The child is nervous, restless, quick of movement, and, 
as a rule, bright of mind. But the characteristic symp- 
tom is a spasm of one or more groups of muscles in the 
face, neck, or shoulders. These muscular contractions 
most commonly occur in the facial muscles. There may 
be rapid winking or blinking of the eyes, with the draw- 
ing of the mouth downward and to one side, distorting 
the face. The eyebrows may be raised or the brow 
lowered, as in frowning. A sudden twisting of the head 
and shrugging of the shoulders are very characteristic 
movements. A peculiar inspiratory sniff, with a lifting 
of the alse of the nostril, occurs in some cases. Habit- 
spasm of muscle groups in the arms and legs may also 
occur, but they are not so common. These habit-move- 
ments may occur at short intervals, and especially when 
the patient is under observation. Attention to and dis- 
cussion of these symptoms always increases the number 
and violence of the contractions. These movements may 
almost or quite disappear during the vacation months, 
especially if these months are spent in the country under 
good hygienic conditions, and with the return of the 
child to school the movements may become more aggra- 
vated. 

The worst cases, as a rule, are seen in the latter 
part of winter or the early spring months. Associated 
with habit-spasm there is not uncommonly a hyperaesthe- 



406 NEUROTIC DISORDERS OF CHILDHOOD 

sia of some portion of the face or neck. In a little patient 
of nine that I now have under treatment there is a marked 
sensitiveness of the ears demanding great care on the part 
of the mother or other attendants lest they should touch 
them when they assist her in dressing her hair or putting 
on her clothes. 

Habit-spasm may continue for many months or even 
years ; as a rule, however, the prognosis is good, provided 
the hereditary taint is not too strong and the child can 
be placed under the most favorable conditions for 
recovery. 

TREATMENT 

As above indicated, the treatment should begin with 
the removal of all abnormal conditions which may pos- 
sibly be a source of reflex irritation. The child should 
be taken out of school, and should receive such mental 
training as is thought necessary at home. Care should 
be taken to protect it from all forms of mental excite- 
ment, and its surroundings should be such that attention 
would never be called to the spasm. In very young 
children the attendants should deny, if necessary, in the 
presence of the child, the very existence of the spasm. 
In older children rewards are sometimes efficacious. 

An outdoor life, with exercise, a carefully selected, 
nutritious diet, and such medication as may be indicated 
to remove the particular anto-intoxication or malnutri- 
tion that may be a basic factor in the individual case is 
in every instance a part of the general treatment. It may, 
for example, be necessary to treat a migrainous diathesis 
or a tubercular anaemia; or it may be necessary to re- 



HABIT-SPASM AND OTHER HABIT-NEUROSES A°7 

move some source of chronic reflex irritation before any 
progress can be made in the treatment of a habit- 
neurosis. 

THUMB-SUCKING 

Thumb-sucking is a habit-neurosis which has its origin 
in the animal instinct of self-preservation, which causes 
the infant to suck everything that comes in contact with 
its lips. The child by instinct conveys to its mouth 
everything that touches its hands, and when nothing 
happens to be in the hand the child places its thumb, 
finger, or some other portion of its body in its mouth. 
In this way the injurious habits of sucking are gradually 
developed. In the beginning the act of sucking some 
portion of the body or some foreign substance is done 
in response to normal instincts, but after a time the suck- 
ing habit is gradually formed, and then the infant, dur- 
ing the greater portion of its waking moments, indulges 
this habit, and seems to get comfort and satisfaction 
from the act. In indulging this habit the infant does 
not, as in the beginning, suck promiscuously anything 
that happens to come in contact with its mouth, but 
confines the habit to some particular object, such as the 
thumb. Among the objects commonly selected by the 
infant for sucking are the thumbs, fingers, toes, tongue, 
a rubber nipple, a piece of cloth, or some toy. 

The habit of sucking does not produce any notable 
constitutional disturbances, and does not apparently in- 
fluence the growth or development of the nervous system, 
and the infant is allowed to form this habit because the 
mother or the physician does not believe it is worth 



408 NEUROTIC DISORDERS OF CHILDHOOD 

while to try to prevent the formation of a habit which 
gives the child a pleasurable occupation and does not 
seriously interfere with its development. 

The sucking habit, however, does produce certain de- 
formities of the part sucked, and may also lead to irregu- 
larities in the development of the mouth. The deform- 
ities of the mouth, thumb, and fingers may, in aggravated 
instances, be so pronounced that they are noticeable when 
the child grows up. It is, therefore, for the purpose of 
preventing these deformities that the sucking habit 
should be prevented, and this can best be done before 
the habit has become thoroughly formed. 

If the child is allowed to indulge in the sucking habit 
for months or years, it is then a very difficult matter to 
overcome it. In such cases the habit can only be broken 
up by some mechanical device which makes it impossible 
for the child to continue it. In some instances, where 
the habit has been indulged in for only a short period of 
time, good may result from covering the thumb or 
fingers or part sucked with solutions of quinine or 
aloes. These bitter solutions, however, are of little value 
where the habit is well formed. 

The mechanical means which may be used to prevent 
the continuance of the habit vary with the individual 
child and with the part of the body sucked. Splints 
may be used which will prevent the child from bending 
the elbow, and thus make it impossible for it to get its 
hand to its mouth. Mittens, gloves and bandages 
for the hands may be tried in suitable cases. The diffi- 
culty which the physician experiences in overcoming the 
habit of sucking should lead him to give more careful 



HABIT-SPASM AND OTHER HABIT-NEUROSES 4O9 

attention to preventing the formation of this habit in 
other children who may come under his care. Punish- 
ment does not, as a rule, correct the sucking habit, 
but rather teaches the child habits of deception. 

Older children may sometimes be influenced by 
rewards or by appealing to their sense of shame. 

The sucking habit is always more difficult of treat- 
ment in nervous and malnourished children, and for this 
reason malnutrition and other causes of nervousness 
should be carefully treated before an attempt is made 
to break up the habit of sucking by mechanical restraint. 

THIGH-FRICTION ( INFANTILE) 

Thigh-friction is a habit-neurosis not infrequently ob- 
served in infants. It is commonly accomplished with 
the child lying on its back ; the thighs are flexed, crossed, 
and pressed tightly together, closely embracing the exter- 
nal genitalia ; in this position the infant makes an up and 
down body movement or rubs the thighs together. These 
movements are apparently attended by a pleasurable ex- 
citement, and there are flushings of the face and an in- 
crease in the general nervous tension. Following this 
act, which continues for a few minutes only, there is a 
general relaxation, accompanied by mild perspiration 
and an apparently quiet contentment. This act may be ac- 
complished by the infant in a variety of ways. At times 
it is done by rubbing the inside of the thighs against some 
object, such as a pillow or other portions of the bed. 

This act, by reason of the pleasurable excitement it 
produces, is repeated from time to time until the habit be- 



410 NEUROTIC DISORDERS OF CHILDHOOD 

comes engrafted upon the nervous system. The habit 
once formed, the infant may practice it many times in the 
twenty-four hours, especially if left alone. In the be- 
ginning it will indulge in thigh-friction quite as openly 
and innocently as it indulges in thumb-sucking or nail- 
biting; but after being restrained from accomplishing this 
act, and finding itself watched with this purpose in view, 
it becomes very secretive, and indulges in the practice 
when not observed. 

Thigh-friction is commonly described as a form of 
masturbation, and very closely resembles this act as prac- 
ticed by older children. Thigh-friction, however, as 
practiced in infancy differs in some particulars from the 
masturbation habit practiced in later childhood. In the 
older child masturbation is a very pernicious practice, 
which has its primary origin in the newly awakened 
sexual instinct which accompanies the development of 
the sexual organs, and in the altogether new and tremen- 
dously intense and pleasurable sensations which accom- 
pany the gratification of this instinct. These indulg- 
ences may be led up to by a neurotic constitution and by 
local irritations; but after a time the masturbation habit 
is formed. This habit is hard to overcome, and even- 
tually produces an instability and irritability of the 
local nervous mechanism involved, and at times pro- 
found functional disturbances of the central nervous 
system — absent-mindedness, mental depression, neuras- 
thenia, and even insanity may result. The tendency of 
the masturbation habit, when excessively indulged and 
long continued, is to produce physical and moral degene- 
racy. 



HABIT-SPASM AND OTHER HABIT-NEUROSES 4 1 I 

Thigh-friction, or this so-called type of infantile mas- 
turbation, presents an altogether different picture, and is 
from a clinical and prognostic standpoint a different con- 
dition. 

Thigh-friction in infancy, because of the rudimentary 
condition of the sexual organs, is not and cannot be ac- 
companied by the intensely sensual sensations which ac- 
company masturbation in later life. It is purely a habit 
neurosis, similar in its etiology to habit-spasm and thumb- 
sucking. The sensations, however, in thigh-friction are 
more intense than they are in the other habit-neuroses, 
because it involves the excitement of that portion of the 
nervous system which is later to control the fully devel- 
oped sexual organs. But these sensations surely do not 
compare in intensity to, and are perhaps very different in 
quality from, those that are afterward produced by ex- 
citing the same nervous mechanism in an older child in 
whom the sexual organs are sufficiently developed to re- 
spond with their physiological function. 

Thigh-friction, like other infantile habit-neuroses, dis- 
appears under proper treatment before the child is four 
years of age. In certain cases where the predisposing 
and exciting causes are not removed, it may persist for a 
longer time ; but in my experience there is no connection 
between this habit and masturbation in later childhood; 
the one does not lead up to and does not predispose to the 
other. Thigh-friction is common in infancy. In early 
childhood both this condition and true masturbation are 
rare. In later childhood masturbation is very common, 
and thigh-friction very rare. Thigh-friction is vastly 
more common in female infants. All of my cases, 



412 NEUROTIC DISORDERS OF CHILDHOOD 

strangely enough, have been of this sex. True mastur- 
bation is much more common in boys, and with them 
the habit becomes more firmly fixed and produces more 
deleterious results. 

The diagnosis of thigh-friction is readily made if the 
physician's attention is called to the symptom group. In 
many instances, however, the diagnosis is never made 
because the infant is not intelligently observed, or because 
the act is considered a trick or innocent habit of not suffi- 
cient importance to be considered seriously. It is my 
belief that most of these untreated cases are cured by the 
mental and physical development of the child. Between 
the third and the fifth year of life there is a tendency to 
spontaneous recovery from this and all other infantile 
habit-neuroses. In children, however, who have inherited 
an intensely neurotic constitution, or in whom there per- 
sists a profound malnutrition or a local genital irritation, 
the habit may continue indefinitely. 

ETIOLOGY 

As above noted, age and sex are important predispos- 
ing factors. The great majority of these cases occur in 
female children under four years of age. 

Heredity. — This is a very powerful predisposing fac- 
tor. Nearly all these children inherit a neurotic con- 
stitution. Gout or tuberculosis is also commonly found 
in the family history. 

Auto or intestinal intoxications are important predis- 
posing factors. Anaemia and general malnutrition pro- 
duced by gastro-intes-tinal diseases, rickets, lymph node 



HABIT-SPASM AND OTHER HABIT-NEUROSES 4 T 3 

tuberculosis, malaria, improper food, impure air, and bad 
hygiene aggravate the general nervous irritability of the 
child and increase the tendency to this and other habit- 
neuroses. 

Exciting Causes. — Local exciting causes commonly 
exist in these cases. Of these Holt says: "The most 
frequent are long or adherent prepuce, phimosis, balani- 
tis, vulvo-vaginitis, eczema of the labia, thread worms, 
and tight clothing. A urine which is irritating because 
of excessive acidity, or the presence of crystals of uric 
acid, may be a cause. Any irritation may lead the child 
to rub the parts in some way, and, a pleasurable sensation 
being excited, this action is repeated until a habit is 
formed." In my own experience a mild vulvo-vaginitis 
and recurrent attacks marked by a hyperacidity of the 
urine are the most common exciting factors which lead to 
the habit of thigh-friction in infants. 

PROGNOSIS 

The prognosis in thigh-friction is very good. If 
properly cared for, children will lose the habit and all 
danger of relapse before they are four years of age. The 
prognosis in masturbation as its occurs in older children 
is, however, a very different matter. These cases are 
very difficult to treat, and the habit, once formed, is kept 
up to a greater or less extent throughout childhood and 
into adult life. 

TREATMENT 

In infantile thigh-friction the first and all-important 
step in the treatment is to place the patient under such 
careful observation or such ingeniously devised mechani- 



4 H NEUROTIC DISORDERS OF CHILDHOOD 

cal restraint as to make the continuance of the habit an 
impossibility. The accomplishment of this purpose in 
some instances is a matter of the very greatest difficulty. 
In the great majority of these cases the act is performed 
only when the infant is lying down and when the thighs 
are flexed. In these cases the infant when awake is to be 
kept in a sitting posture, or when lying down is to be 
carefully watched by a thoroughly trustworthy nurse. 
When it is taken for an outing, if it is old enough to sit 
up, the go-cart is to be preferred to the baby-carriage. 
During sleep the infant should either be carefully 
watched or should be held by some mechanical contrivance 
in such a way that the act will be impossible. If the in- 
fant sleeps in pajamas, the heels of this garment may be 
fastened by safety pins to the mattress in such a manner 
as to hold the legs apart and prevent the flexion of the 
thighs; at the same time the child's body is prevented 
from slipping down in the bed by a ribbon stretching 
from the back of the pajamas to the head of the bed. I 
have used some such device as this many times with great 
success, and I have found it more satisfactory than nightly 
vigils over the sleeping infant. Many mechanical devices 
have been recommended, all of which have in view the 
forcible prevention of thigh-friction. The profound 
sleep of the young child lends itself to this mode of treat- 
ment, and the patient quickly becomes accustomed even 
to such cumbersome appliances as the double thigh splints 
with a separating footboard which have been recom- 
mended in troublesome cases. No special device, how- 
ever, is suitable to all cases, but if the physician is suffi- 
ciently impressed with the necessity for this method of 



HABIT-SPASM AND OTHER HABIT-NEUROSES 415 

treatment, the particular mechanical device by which the 
end is to be accomplished may be left to his ingenuity. 

In treating older children for the masturbation habit 
the above methods do not apply. Forcible restraint in 
these cases does more harm than good. Neither is cor- 
poral punishment of value. These are the cases that 
are most difficult and discouraging to treat. There is 
little that the physician can do except to remove, if pos- 
sible, all predisposing and exciting factors. The malnu- 
trition may be treated and the cause of local genital ir- 
ritations removed. The common sense, pride, and judg- 
ment of the child are also to be appealed to, but this 
is usually better done by the mother than by the phy- 
sician. But even when all these measures for the con- 
trol of the masturbation habit in the older child are 
carried out, the results are far from satisfactory, since 
the majority of these cases are little influenced by these 
measures. 

In this chapter, however, we are more especially con- 
cerned with the infantile habit-neurosis thigh-friction, in 
which the prognosis is most favorable, and in which the 
control of the habit by mechanical measures is a long step 
in the cure. This interruption breaks into and helps to 
destroy the habit which has been engrafted on the nerv- 
ous system, and in that way makes for the permanent 
cure of the affection. The habit interrupted, the next 
most important step in the treatment is the removal of all 
possible sources of genital irritation. The preputial hood 
should be separated from the clitoris, and vulvo-vaginitis, 
if it exist, should be carefully treated. Phimosis, pre- 
putial adhesions, pin worms, and other causes of genital 



416 NEUROTIC DISORDERS OF CHILDHOOD 

and rectal irritation are to be carefully sought for and 
treated. The clothing of the infant is to be so adjusted 
as not to irritate the genitals. Infants having a ten- 
dency to increased acidity of urine should be given ben- 
zoate of soda put up in palatable solution. Either this 
or some other alkali should be given daily for months 
to prevent the recurring attacks of increased acidity of 
urine which are present in many of the cases of thigh- 
friction. 

Lastly, but of not less importance, is the treatment 
looking to the removal of the nutritional disturbances 
and general nervous irritability which are such impor- 
tant predisposing factors in many of the cases of thigh- 
friction. This treatment embraces an out-of-door life 
free from excitement and mental stimulation, a carefully 
selected diet, and medicines suitable to the form of in- 
toxication or malnutrition from which the infant suffers. 



CHAPTER XXVII 

PICA, OR DIRT-EATING, IN CHILDREN 

Pica is a habit-neurosis which manifests itself in a per- 
verted appetite. Patients having this disorder eat all 
kinds of indigestible and innutritious substances, such as 
plaster, clay, sand, cinders, ashes, and dirt, which to a nor- 
mal appetite would be repulsive or disgusting. The term 
pica is taken from the Latin name of the jay or magpie, 
because of its supposedly greedy appetite. The peculiar 
perversions of appetite which occur in this condition have 
some analogies to the well-known gastric neurosis — buli- 
mia. Bulimia, however, is an exaggeration of the normal 
appetite, and is characterized by an almost insatiable 
craving for food which for the most part is wholesome. 
The patient suffering from this condition may eat at short 
intervals enormous quantities of food, as much as twenty 
or twenty-five pounds in twenty-four hours, without im- 
mediate discomfort and often without any bad after- 
effects. 

In pica, on the other hand, the appetite is so perverted 
that normal food in any quantity does not satisfy the un- 
natural cravings, which demand not large quantities of 
food, but unwholesome and repulsive substances which 
have, as a rule, little or no food value. 

Perversion of appetite similar to pica, as it is mani- 
fested in man, also occurs in such animals as dogs, sheep, 
and goats. Young lambs sometimes manifest this ten- 

417 



41 8 NEUROTIC DISORDERS OF CHILDHOOD 

dency by eating wool, hair, and dirt in preference to the 
grass of the rich pasture upon which they are wont to 
graze. 

A clear conception of this neurosis, as it is manifested 
in children, can only be had by a careful study of the 
great variety of etiological factors which have been ac- 
cused of producing pica. 

GENERAL ETIOLOGY 

Predisposing Causes. — Insanity and feeble-mindedness 
are predisposing causes. Pica occurs as a pure psychosis 
in about 15 or 20 per cent, of insane and feeble-minded 
individuals. This class of patients, however, are not in- 
clined to select certain substances which they take instead 
of food, but they fill their stomachs with all kinds of ma- 
terials that may come in their way, such as pieces of 
dress, bedding, sand, or more disgusting materials, and 
on another occasion these same patients may fill their 
stomachs with entirely different things. This condition, 
therefore, as it manifests itself in the insane, is not so 
much due to a perverted appetite as it is to a condition 
of mind in which judgment and discretion are lacking, 
and in which the animal instinct of self-preservation so 
predominates that they instinctively put everything into 
their mouths with which their hands come in contact. In 
these patients this practice does not produce a desire for 
certain definite materials as it does in the young child, 
and should not, therefore, be classified under the neurosis 
we are now describing. 

Age. — Cases of pica occur at all ages. A mild form 
of this condition is very commonly seen in infants, and 



PICA, OR DIRT-EATING, IN CHILDREN 419 

the more severe types are seen in children and young 
adults. In later life the condition is rarely observed. 

Sex. — The large number of cases that occur in infancy 
are about equally divided as to sex. In early childhood 
there is a slight preponderance of females, and the cases 
occurring in adults are almost wholly confined to this 
sex. 

Heredity. — There is, as a rule, a strong neurotic 
family history. Writers upon this subject have also re- 
corded that in many cases there is a direct inheritance of 
the dirt-eating habit. It is more probable, however, that 
in these cases the child, having inherited the neurotic 
temperament, contracts the dirt-eating habit by imitation. 

Malnutrition is a very potent etiological factor in a 
large percentage of the cases. In the infantile cases, 
rickets, intestinal disease, and lymph node tuberculosis, 
combined with bad hygiene, lack of sunshine, and im- 
proper and badly prepared food, are etiological factors 
of importance. 

In children and young adults chlorosis, well-marked 
anaemia, and more or less profound nutritional disturb- 
ances are almost always present, and are believed to be 
very common and very powerful predisposing causes of 
pica. 

Menstrual disorders and hysteria are very commonly 
associated with this condition in older children, and in 
young adults. 

Pica is not infrequently an hysterical manifestation, 
and in many cases seems to be closly related to disturb- 
ances of the menstrual function. Cases of amenorrhcea 
and menorrhagia occurring in hysterical girls are often 



42 O NEUROTIC DISORDERS OF CHILDHOOD 

associated with dirt-eating. These cases are, as a rule, 
anaemic and malnourished. Samuel Wright reports in 
the Medical Times, 1847, tne case °f a young girl, aged 
twenty, who was malnourished, had not menstruated for 
four years, and was employed as a glass polisher. She 
acquired the habit, as did one of her companions em- 
ployed in the same business, of eating the Fuller's Earth 
which she used in polishing. He estimated that she 
swallowed " in one year and a half nc less than twelve 
hundred ounces of aluminous earth." Under careful 
treatment she slowly convalesced. 

Edward Rawson in the Medical Press of 1881 reports 
the case of a girl, aged eighteen, very anaemic, profoundly 
malnourished, marked nervous symptoms, and had not 
menstruated for three years. She came into the hospital 
suffering from an abdominal tumor, and in response to a 
powerful cathartic a large bucketful of rags came away. 
Among them were ribbons eighteen inches long, pieces 
of velvet, handkerchiefs, and large pieces of cloth. 

A. M. Gould in the Boston Medical and Surgical Jour- 
nal, 1876, reported a case of pica, aged forty-three, fe- 
male, anaemic, has dyspnoea, and suffers from menstrual 
disturbances. " For two years she has had a longing for 
innutritious articles. At first she ate charcoal ; at present 
fine sand and gravel. She asserts that she has eaten 
1 nearly a bushel of sand, and takes daily from a table- 
spoonful to a cupful.' " 

The medical literature is full of cases of this descrip- 
tion that appear to be etiologically related to hysteria, 
menstrual disturbances, anaemia, and general malnutri- 
tion, 



PICA, OR DIRT-EATING, IN CHILDREN 4^1 

Exciting Causes. — Imitation and mimicry are impor- 
tant exciting factors. In many instances the individual 
has the practice of dirt-eating suggested to him by con- 
tact with others who have the habit. Following this 
suggestion in imitation or in a spirit of mimicry, he be- 
gins the practice, which afterwards becomes a habit. This 
to my mind explains the fact that pica has occurred 
endemically from time to time in almost every quarter 
of the globe. Dr. Foot, in describing and explaining the 
prevalence of pica among the natives of Jamaica, says: 
" Negroes have been overheard urging their companions 
to indulge in the habit of dirt-eating." Among neurotic 
and anaemic girls working at trades in which they have 
to handle chalk, Fuller's Earth, sand, and clay, pica is 
not uncommon. Propinquity and imitation are respon- 
sible for beginning the practice of dirt-eating under such 
conditions. Chalk-eating among school children, having 
a like origin, is not infrequently the beginning of a 
habit which develops into pica. Imitation and mimicry 
are especially strong characteristics of the childish mind, 
and they are therefore potent factors in the development 
of many of the neuroses of childhood. This is especially 
true of certain of the habit-neuroses, such as pica and 
habit-spasm. 

The animal instinct of self-preservation is a very im- 
portant factor in developing this neurosis in infants. 
It is this instinct which causes them to put everything that 
touches their hands into their mouths, and is therefore 
largely responsible for developing the habit, the after-in- 
dulgence of which constitutes the infantile type of pica. 
Plaster from the wall, dirt scraped from boots or the 



422 NEUROTIC DISORDERS OP CHILDHOOD 

floor, ashes and cinders from the fireplace, and sugar and 
candy from the nursery, are the most accessible materials. 
The infant's hands coming in contact with one or more of 
these articles, they are conveyed to the mouth and 
swallowed. This instinctive act of the infant is repeated 
time and again, until a habit is engrafted and a desire 
created, the gratification of which gives pleasure or satis- 
faction, and when once the habit is formed of taking one 
of these substances, the number of innutritious things 
which the child swallows may be gradually enlarged until 
it contains the whole available list. 

It will thus be seen that propinquity and opportunity, so 
far as the child's contact with materials is concerned, 
have much to do with the development of this habit in 
infancy. And this is also true with older children and 
adults. It not uncommonly happens that predisposed in- 
dividuals begin a practice which leads to the habit of 
dirt-eating by reason of the fact that they are handling 
daily in their occupations certain materials, such as chalk, 
Fuller's Earth, sand, or clay; the practice of taking into 
the mouth any of these articles may lay the foundation 
for the dirt-eating habit. 

Pregnancy is an exciting cause which may develop pica 
in nervous, malnourished, or anaemic individuals who are 
predisposed to this condition. Pregnant women may 
have perversions of appetite which create a desire for un- 
wholesome and innutritious articles, such as chalk, cin- 
ders, coals, etc. This condition as it is manifested in 
pregnant women is a true neurosis, perhaps reflex in its 
origin and similar in its etiology to the vomiting which 
occurs in this condition. It is perhaps dependent upon 



PICA, OR DIRT-EATING, IN CHILDREN 423 

some neurotic disturbance of the functions of the stomach, 
producing a burning, gnawing, or disagreeable sensation 
which is relieved by the taking of such articles as chalk, 
ashes, and cinders. The pica of pregnancy, however, 
passes away with the condition which produced it, and 
does not become a fixed habit. 

Functional disturbances of the stomach, producing a 
burning, gnawing, or aching sensation which is relieved 
by taking into the stomach food or other absorbents and 
diluents, is a very important factor in developing pica in 
many cases. This local manifestation of a general neu- 
rotic condition is very commonly associated with hysteria, 
menstrual disturbances, chlorosis, and the anaemia and 
general malnutrition which results from rachitis, tuber- 
culosis, chronic intestinal disorders, and other chronic 
anaemia producers. 

Foot says, in the Dublin Quarterly Medical Jour- 
nal of 1867, that " in the dyspepsia with which the 
negroes of Jamaica become infected when exposed to 
hardships and privations, a prominent symptom is a 
tormenting gnawing pain in the stomach, and it is for 
the relief of this uneasy symptom that the sufferer be- 
takes himself to eating some absorbent earth which af- 
fords temporary relief." 

Dr. Mason, who studied the endemic pica of Jamaica, 
is inclined to consider that " this habit, as observed among 
these negroes, instead of being a disease, or the cause 
of disease, is actually a remedy prescribed in a rough way, 
the absorbent earth made use of being only injurious 
from the many impurities they contain." 

Intestinal irritation from worms, indigestion, or catarrh 



424 NEUROTIC DISORDERS OF CHILDHOOD 

is very commonly associated with the dirt-eating habit in 
infants and young children, and is believed by medical 
writers to be etiologically related to this neurosis. 

Many of these cases are associated with worms in the 
intestinal canal. Bacot, in the Australian Medical 
Gazette of 1892, speaks of an epidemic of pica that oc- 
curred in and around Cairns in North Queensland, the 
principal characteristics of which were an inordinate ap- 
petite for red clay. This epidemic occurred among chil- 
dren, several of whom died. He reports two of these 
cases, one of which, Lucy H., four years of age, com- 
menced to eat red clay, and this was followed by wood 
ashes and dirt scraped from the floor. She died some 
months later, and the post-mortem records the following : 
" The body was bloodless, mesenteric glands enlarged, 
and the duodenum, jejunum, and upper part of the ileum 
contained multitudes of round worms adhering to the 
mucous membrane, and many pin worms in the 
caecum." 

Dukes, in the Lancet, 1884, reports the case of a child 
aged five years who was brought to him to be treated for 
round worms. Some time later the mother noticed that 
the child ate the soil in the garden. She said she ate the 
earth to relieve the gnawing pain in her stomach. So 
urgent was the demand for this soil-eating that the child 
would, if she could not get earth, eat sand and mortar. 
This habit continued for two years, and during that time 
she passed about one hundred large, round worms. 

While the literature of this subject affords ample evi- 
dence that many cases of pica are associated with intes- 
tinal worms, and while it is also possible that the presence 



PICA, OR DIRT-EATING, IN CHILDREN 425 

of worms in the intestinal canal may be responsible for 
perversions in the functions of the stomach which might 
be etiologically related to pica, yet it is not by any means 
certain that the worms are not the result rather than the 
cause of the dirt-eating in these cases. But even if we 
assume that the worms are the result, rather than one of 
the primary causes, one may yet believe that once the 
worms have taken up their habitat in the intestinal canal 
they may increase the morbid appetite, and thus produce 
a vicious circle becoming a secondary etiological factor. 

Intestinal catarrh, or intestinal disturbances of some 
kind, is one of the most constant accompaniments of pica 
in children under two years of age. Here again it is 
difficult to decide whether the intestinal disturbances are 
a cause or a result of the pica. Children of this age are 
very subject to pica in a mild form, and one is frequently 
called to see children suffering from intestinal disturb- 
ances who have been addicted to the habit of plaster- or 
dirt-eating for many months. These cases may be found 
to suffer from more or less constant indigestion, or in 
other instances the child will recover for a time from both 
the intestinal catarrh and the pica, and after an interval 
of weeks or months both the pica and intestinal disorder 
return. Whether or not the intestinal disturbance in 
these cases is a cause or a result of the pica, it seems plain 
that the intestinal irritation exaggerates the child's gen- 
eral nervousness and increases its morbid appetite. 

Habit is by far the most important of all the etiological 
factors of pica. This condition is in fact a habit-neurosis. 
That is to say, whatever predisposing or exciting factors 
may have been active in starting the practice which leads 



426 NEUROTIC DISORDERS OF CHILDHOOD 

up to dirt-eating, it is the habit which is formed by these 
practices which impels the patient to continue to satisfy 
this perverted appetite. The influence of this factor is 
illustrated in the following case : 

E. F., male, seven years of age. Had always been 
nervous, but had never suffered from any severe illness. 
Some years ago he developed an unusual appetite for 
sweets. This appetite grew by indulgence, until at the 
time I first saw him he was living entirely upon candy 
and sugar. His father, who is a physician, stated that for 
three or four weeks he had not taken a mouthful of any 
other food. He was thin, pale, and nervous, but still had 
a good deal of endurance. He was on his feet the greater 
part of the day, played with other children, and ate candy 
and sugar at short intervals during his waking hours. In 
trying to break up this pernicious habit we attempted to 
starve him into taking other foods, giving him all the 
water he wanted, but withholding sweets. He could not, 
however, be forced to take other food, and as he became 
very weak we were forced at long intervals, twelve or 
twenty-four hours, to give him some candy to eat. We 
then resorted to rectal feeding, and to the introduction of 
milk and other foods into the stomach through a tube. 
These methods were so disagreeable to him that he 
gradually came to drinking milk and eating bread. After 
months of careful supervision the father's perseverance 
was rewarded by seeing the boy's appetite for wholesome 
food returning. But his convalescence was assured only 
by a total abstinence from sweets and a constant insist- 
ence on the taking of milk and bread at proper intervals. 

A somewhat similar case is spoken of by Dr. Foot, who 



PICA, OR DIRT-SATING, IN CHILDREN 427 

says : " Among the cases of pica observed by Sir D. 
Corrigan is one in which this depraved condition of the 
appetite was traced to the acquired habit of eating sugar. 
On this child having been weaned and transferred to the 
nursery, the nurse in charge gave the child lumps of 
sugar, with the object of keeping her quiet at night. The 
morbid appetite for sugar increased to such a degree that 
the child would at last take no food, not even broth, un- 
less loaded with sugar. From a desire to have a lump of 
sugar in the mouth, the child then turned to other sub- 
stances, and was never contented unless she had some- 
thing in the mouth. Clay came most easily to her, as 
she was frequently in a small garden; and when in the 
house twine was the next favorite for sucking and swal- 
lowing. 

Pica, as it occurs in infancy, has more or less decided 
characteristics. These cases are milder than those that 
occur in childhood and adult life; they are, as a rule, 
complicated by or associated with some gastro-intestinal 
disturbance, and while habit becomes the important 
etiological factor in these cases, the habit is not so firmly 
fixed but that in nearly all of these cases it passes off un- 
der mild restraint before the child is three years of age. 
The mental development of the child, which makes it 
more amenable to discipline and which places its appetite 
and desires under better inhibitory control, is perhaps an 
important factor in the cure of these cases. John Thomp- 
son, in the Edinburgh Hospital Reports, 1895, expresses 
the opinion that all these infantile cases manifest a 
tendency to spontaneous recovery in the third or fourth 
year of life. 



428 NEUROTIC DISORDERS OF CHILDHOOD 

Samuel Wright, in speaking of a case of pica in a young 
woman twenty years of age, clearly illustrates the role 
that habit may play in the development of these cases in 
older children and in adults. He says : " She assured 
me that she never in her life had the least desire to put 
anything not eatable into her stomach, until it occurred to 
her one day, she knew not why, to bite a piece of Fuller's 
Earth. 

" She occupied herself some time in chewing it and 
turning it about her mouth, and at last, when lique- 
fied, swallowed it. This led to the taking of another 
piece, and to another, and so on, until the practice be- 
came agreeable as a mode of pastime. From this it grew 
into a pursuit of gratification, and at last the indulgence 
created a positive appetite. The desire became so strong, 
and the necessity for its satisfaction so urgent, owing to 
usage, that even the eating of substantial food did not 
atone for the absence of the filth longed for. Thus, 
whenever the inclination grew dominant it was answered 
by an immediate partaking of the material sought; and 
thus, also, was the morbid appetite increased and con- 
firmed.' , 

Lack of proper training and proper supervision may 
be mentioned as accessory factors in the production of 
this neurosis, since it is fair to presume that under proper 
supervision, especially in infants, this habit could not be 
formed. 

Fright, anger, home-sickness, grief, and other emo- 
tional causes may aggravate the habit of dirt-eating, or 
may cause the individual to return to the habit, if it has 
been discontinued for but a short time. 



PICA, OR DIRT-EATING, IN CHILDREN 429 

SYMPTOMS 

A detailed account of the symptoms which constitute 
and which are associated with the syndrome of pica has 
already been given in the previous pages. Patients with 
pica have strange perversions of appetite which lead them 
to forego wholesome, appetizing food for such innutri- 
tious and indigestible things as plaster, sand, gravel, 
chalk, Fuller's Earth, dirt, clay, ashes, cinders, coal, soap- 
stone, slate pencils, paper, rags, and sometimes such dis- 
gusting materials as their own excrement. In some 
instances these individuals will give up all other food 
except sweets, such as candy and sugar. This sugar-eating 
habit not uncommonly leads to dirt-eating and the de- 
velopment of troublesome and disgusting types of pica. 

Many patients who practice the habit of dirt-eating 
may also take for a considerable time a sufficient quantity 
of nutritious food. The tendency, however, is to grad- 
ually increase the quantity of dirt taken and to gradually 
diminish the quantity of wholesome food. In such cases 
the patients' general health suffers. They become anae- 
mic, malnourished, emaciated, and more nervous than be- 
fore. These patients are, as a rule, constipated by reason 
of the accumulations of dirt in the large intestine. The 
constipation is sometimes so obstinate that it results in 
obstruction of the bowels, and threatens or takes the life 
of the patient. Profound nutritional disturbances are 
much more commonly associated with pica, as it occurs 
in the older child and adult, than in the infant. 

Dr. Foot in speaking of pica, as it occurs among the 
negroes of Jamaica, says : " Whatever the motive may 



43° NEUROTIC DISORDERS OF CHILDHOOD 

be that induced them to begin the practice, it soon proves 
fatal if carried to great excess. There are instances of 
their killing themselves in ten days, but this is uncommon, 
and they often drag out a miserable existence for several 
months, or even one or two years. On many estates half 
the number of deaths on a moderate computation are due 
to this cause. The negroes subject to pica almost always 
complain of incessant pain in the. stomach. On examina- 
tion of the body after death there are frequently found 
in the colon large concretions of the earthy matter which 
they have swallowed, lining the cavity of the bowel and 
almost completely obstructing the passage." There are 
also many reported cases where death has occurred from 
perforations of the stomach or intestine from the soap- 
stone or other hard materials which have been swallowed. 

The infantile type of pica, however, which has been 
previously described, and which is common with us, 
bears little resemblance to this severe type of the disease, 
which has occurred endemically in almost every quarter 
of the globe. Infantile pica is, for the most part, a mild 
habit-neurosis somewhat analogous in its etiology to such 
habit-neuroses as masturbation, habit-spasm, and thumb- 
sucking. This condition is very commonly associated 
with gastro-intestinal disturbances and worms. They 
also suffer from more or less marked nutritional disturb- 
ances. Many of them have complexions that are dull 
and murky, and they may be thin, anaemic, or even cachec- 
tic. Many of these cases, however, especially before 
the habit is well formed, show very slight nutritional 
disturbances. 

The prognosis in pica is good. This is especially true 



PICA, OR DIRT-EATING, IN CHILDREN 43 1 

in the infantile cases, as all of them get well under proper 
treatment before they are four years of age. The aver- 
age duration of these cases has been estimated at twenty 
months. 

TREATMENT 

The first step in the treatment is to so place the patients 
under such supervision that it is absolutely impossible for 
them to continue the habit. It is futile to attempt to over- 
come this habit, especially where it is strongly intrenched, 
by persuasion, by rewards, or by punishment. These 
measures, as a rule, fail. It is advisable, therefore, es- 
pecially in older children and in young adults, to begin the 
treatment in a hospital or some other institution where 
they can be kept under proper control. The change of 
surroundings is a mental factor which assists these 
patients in giving up the habit. In young infants it is 
advisable to place them in the hands of a thoroughly com- 
petent nurse. If the habit is thus forcibly broken up, it 
gradually loses its hold upon the nervous system, and this 
measure is, therefore, of itself a curative one. 

The next important step is to prescribe a proper dietary 
which is suitable to the age and digestive capacity of the 
patient. The food problem is especially important in the 
treatment of infantile cases, since these cases are com- 
monly complicated with gastro-intestinal disturbances, 
and the first step in their treatment comprehends the re- 
moval of all gastro-intestinal irritation and the restoration 
to a normal condition of the digestive functions. 

In older children and young adults the treatment com- 
prehends the removal of the predisposing causes where 



43 2 NEUROTIC DISORDERS OF CHILDHOOD 

this is possible. The causes which produce anaemia and 
general malnutrition are to be carefully searched for and 
treated, and in short the object of the treatment is to im- 
prove the general health of the patient and to overcome 
his nervous tendencies. There is no specific medical 
treatment indicated which will apply to all cases of pica, 
but medicines are sometimes of great value where the 
morbid appetite is associated with a burning, gnawing, 
nervous sensation in the stomach. In these cases alkalies, 
such as bicarbonate of potash or bicarbonate of soda, may 
in the beginning of the treatment be of decided value in 
giving relief to this sensation. Bitter tonics and hydro- 
chloric acid may also in some cases be beneficial in modi- 
fying the stomach sensation which is associated with the 
perverted appetite. For the relief of the anaemia and 
general malnutrition, iron and cod-liver oil are of value. 



INDEX 



Acetone, relation of, to diacetic 
and oxybutyric acids, 68 
Acetone-bodies, origin of, 68 
Acid intoxications, 65-70 

how produce symptoms, 65 
in recurrent vomiting, 227 
Aducco, 95 

Alkalies in treatment of recur- 
rent vomiting, 229 
Anaemia, a cause of chorea, 320 
blood changes in, 93 
chronic, 93 
explanation of nervous 
symptoms in, 96 
influence of, on nerve cen- 
ters, 95 
partial starvation in, 98 
Anaemic headaches, 355 
Anaesthesia in hysteria, 341 
Arthritis, heart disease, and 
chorea, syndromes pro- 
duced by the same poison, 
312 
Asphyxia, a cause of convul- 
sions, 143 
Astasia abasia, 337 
Asthma, 366 
adult type of, 372 
change of climate in, 376 
etiology of, 369 
exciting factors of, 370 
pathology of, 366 
predisposing factors, 369 
prognosis of, 374 
symptoms of, 372 

433 



the interval treatment of, 

375 

treatment of attack, 374 

two distinct types of, 369 

Auto-intoxications, 59 

Bouchard's work on, 60 

from biliary secretion, 6$ 

from carbonic acid, 70 

from excessive action of 

thyroid gland, 61 

from oxalic acid, 72 

from uric acid bodies, Jz 

Autotoxins, a cause of asthma, 

370 
a cause of eclampsia, 142 
enuresis, 179 

epilepsy, 240 

fever, 127 

headaches, 359 

Autotoxins, a cause of mi- 
graine, 195 
a cause of recurrent coryza, 
261 
a cause of recurrent vom- 
iting, 218 
origin of, 59 
protection against, 60 
Autumnal coryza, 265 
symptoms and treatment 
of, 266 



Bacterial products, the cause of 

fever, 125 

Bacterial toxaemias, 85 



434 



INDEX 



Bacterial toxins, chronic, 86 
importance as fever pro- 
ducers, 85 
Biliary toxaemia, 63 
Brain, functional development 
of, 21 
growth of, 21 
important peculiarities of, 
during infancy, 22 
immaturity of, at birth, 21 
membranes of, at birth, 21 
Brain- work, excessive, a factor 
in neurotic disease, 112 
Bromides in epilepsy, 257 
Bronchitis sibilant, 373 



Calcium starvation, 99 

Carbonic acid intoxications, 70 

Child is not a little man, 113 

Chorea, 302 

anaemia in, 320 

exciting causes of, 314 

general etiology of, 305 

habit in, 402 

heart disease in, 311 

heart symptoms of, 321 

idiopathic, 304 

malaria, a cause of, 314 

medical treatment of, 323 

mental symptoms of, 320 

organic, 302 

prognosis of, 316 

recurrence of, 315 

rheumatism as a factor, 307 

symptoms of, 316 

toxic, 304 

treatment of attack, 321 

treatment of underlying 

condition, 326 

Chorea, tuberculosis, a factor 

of, 313 



Christopher, Walter H., 08 

Clinical study of recurrent vom- 
iting, recurrent coryza, 
toxic epilepsy, and mi- 
graine, 268 
Clouston, T. S., 22 
Constipation, a factor in mi- 
graine, 193 
in intestinal toxaemia, 48 
in recurrent vomiting, 222 
Convulsions, chloral hydrate in, 

154 

chloroform in, 153 

partial or general, 147 

prognosis of, 147 

Convulsive centers, location of, 

29 
Convulsive disorders, compara- 
tive immunity from, in 
young infants, 28 

frequency of, in childhood, 
137 
Coryza, recurrent, 261 



Developmental epilepsy, 236 

Digestive disturbances, a cause 

of insomnia, 391 

a cause of night-terrors, 382 

Disorders of sleep, 378-380 

Dirt-eating in children (see 

pica), 417 

Earache, 361 

Eclampsia, 136 

aids in making prognosis, 

149 

age as a factor in prognosis, 

147 

diagnosis of, ISO 

due to organic lesions, 144 

etiology of, 136 

exciting causes of, 14 1 

hysterical, 344 



INDEX 



435 



in laryngismus stridulus, 
162 

in recurrent vomiting, 225 

symptomatojogy of, 145 

treatment of, 152 

Enuresis, 175 

causes of, 177 

habit a factor in, 183 

prognosis of, 184 

symptoms of, 183 

three factors of, 175 

treatment of, 185 

Environment, an important 

cause of hysteria, 333 

Epilepsy, 144-235 

developmental, 236 

diagnosis of, 251 

general etiology of, 244 

grand mal, 246 

Jacksonian, 238 

medical treatment of, 257 

mental symptoms of, 250 

most common type of, 253 

nocturnal, 250 

organic, 238 

pathology of, 236 

petit mal, 247 

prognosis in, 254 

symptomatology of, 246 

toxic, 240 

treatment of, 254 

Fat starvation, a cause of nerv- 
ous symptoms, 98 

Feeble inhibition, a factor in 

epilepsy, 237 

Fever, 123 

antipyretics in, 134 

definition of, 33 

diet in, 133 

exciting causes of, 125 

from reflex causes, 130 



more variable in children 

than in adults, 40 

physiological causes of, 123 

predisposing causes of, 124 

treatment of, 132 

Forchheimer, F., 128 

Fright, a cause of chorea, 314 

a cause of hysteria, 336 

Gad, J, 14, 43 

Gastric disturbances, a cause of 

pica, 423 

Gastro-intestinal toxaemia, 45 

a factor in tetany, 168 

etiological factors of, 48 

Gray, Landon Carter, 242 

Griffith, J. P. C, 166, 226 

Gyrospasms, 268 

Habit-spasm, 402 

etiology of, 402 

exciting factors of, 403 

symptoms of, 405 

treatment of, 406 

Hay-fever, 265, 368, 371 

Headaches, 355 

anaemic, 355 

etiology of, 355 

migrainous, 192 

neurasthenic, 356 

organic, 361 

reflex, 357 

toxic, 359 

treatment of, 362 

Head-movements, vibratory, 397 

Head-nodding, 395 

Heart disease in rheumatism, 

3ii 
Heat centers, 34 

influence of, in producing 
variations of body tem- 
perature, 36 



436 



INDEX 



influence of malnutrition 

on, 40 

location of, 35 

when developed, 37 

Heat dissipating mechanism, 41 

Heat stroke, a cause of fever, 

128 
Hemorrhage, a cause of convul- 
sion, 143 
Herter, C. A., 71, 244 
Hodge, C. R, 107 
Holt, L. K, 128, 165, 373, 413 
Howell, W. H., 99 
Hysteria, 328 
emotional factor in, 338 
etiology of, 329 
excessive nerve activity and 
mental strain, factors of, 

335 
lack of home discipline, a 

factor in, 335 

pathology of, 328 

rest-cure in, 352 

strain of school life, a 

cause of, 334 

symptomatology of, 336 

suggestion in treatment of, 
350 
treatment of, 348 

Hysterical anaesthesia, 341 

aphonia, 339 

eclampsia, 344 

hyperesthesia, 342 

hyperpyrexia, 347 

joint diseases, 343 

paralysis, 340 

Idiopathic chorea, 304 

Incontinence of urine, 175 

Infections, a cause of convul- 
sions, 142 
Inhibition, abnormally feeble, 25 
development of, 24 



Inhibition, feeble, a cause of 
eclampsia, 138 

a cause of enuresis, 178 
epilepsy, 237 

fever, 37, 123 

hysteria, 328 

night-terrors, 383 

Inhibition, involuntary, 25 

Insomnia, 390 

etiology of, 390 

treatment of, 392 

treatment of underlying 
causes, 392 

Insulation, a cause of convul- 
sions, 142 
Intestinal irritation, a cause of 
pica, 425 
Intestinal toxaemia, acute, 50 
as a complication, 55 
chronic, 53 
importance of vegetable or- 
ganisms in, 56 
nervous symptoms pro- 
duced by, 54 
the urine in, 56 
Intestinal worms, convulsions 
produced by, 58 
Intestinal toxins, a cause of 
eclampsia, 141 
a cause of epilepsy, 243 
enuresis, 180 
fever, 125 
headaches, 359 
insomnia, 391 
Intestinal toxins, a cause of 
migraine, 195 
a cause of night-terrors, 382 
a cause of recurrent coryza, 
261 
a cause of recurrent vomit- 
ing, 218 
a cause of tetany, 168 
origin of, 45 



INDEX 



437 



Jacobi, A., 
Koplik, Henry, 



133 

165 



La Fetra, L. R, 373 

Laryngismus stridulus, 158 

etiology of, 158 

prognosis of, 162 

symptoms of, 161 

treatment of, 163 

Leyden's periodical vomiting, 

225 
Liver, role of acid intoxications, 

70 
Liver incompetency, in mi- 
graine, 195 
in recurrent vomiting, 219 



Malaria, nervous symptoms of, 

9i 
Malnutrition, a cause of chorea, 

313 
a cause of eclampsia, 140 
enuresis, 179 

fever, 124 

headache, 355 

hysteria, 332, 335 

insomnia, 390 

night-terrors, 381 

tetany, 168 

Masturbation, 410 

Migraine, 192 

chronic, 201 

diagnosis of, 201 

dietetic and hygienic treat- 
ment of, 215 
direct causes, 194 
etiology of, 192 
exciting causes of, 197 
how poisons act in produc- 
ing, 196 
kinship to epilepsy, 242 



kinship to recurrent vomit- 
ing, 217, 228 
predisposing causes, 192 
Migraine, prognosis of, 202 
symptomatology of, 198 
treatment of, 203, 206 
Mitchell, Weir, 352, 402 
Morphin in convulsions, 155 
in recurrent vomiting, 230 
Morse, J. L., 165 
Motor nerve cell, highest func- 
tional development of, 15 
Muscular action, a cause of fe- 
ver, 125 

Nerve activity, excessive, 112 

Nerve cells, changes in from 

electrical stimulation, 109 

changes in from peripheral 

irritation, 109 

fatigue changes in, 107 

function of, 13 

highest function of, 13 

normal functions of, 13 

Nerve energy, discharge of, 15 

discharged involuntarily, 16 

discharged reflexly, 17 

discharged voluntarily, 17 

feeble inhibition of, 24 

generation of, 14 

how generated, 14 

involuntary inhibition of, 19 

overflow of, 27 

voluntary inhibition of, 17 

Nerve excitement, a factor in 

neurotic disease, 112 

Neurasthenic headaches, 356 

Night-terrors, 380 

central and idiopathic, 383 

etiology of, 381 

exciting causes of, 382 

prognosis of, 388 

related to epilepsy, 385 



438 



INDEX 



symptoms of, 384 

symptomatic, 386 

two types of, 383 

treatment of, 388 

Nystagmus, and associated head- 
movements, 395 
character of movements, 395 
etiology of, 397 
exciting causes of, 399 
pathology of, 399 
prognosis of, 400 
treatment of, 401 



Organic chorea, 


302 


epilepsy, 


238 


headaches, 


361 


Osier, William, 


307, 368 


Ott, Isaac, 


39, 130 



Oxalic acid intoxication, 72 

Oxybutyric acid intoxications, 

67 



Packard, F. A., 


371 


Paralysis in hysteria, 


339 


Pavor nocturnus, 


380 


Peterson, F., 


395 



Physiological factors of fever, 

Physiological peculiarities of the 

young nervous system, 21 

Pica, 417 

definition of, 417 

predisposing causes, 418 

exciting causes, 421 

a habit neurosis, 425 

symptoms of, 429 

the infantile type of, 427, 430 

treatment of, 431 

Playgrounds for children, 119 

Polypnoea, 43 

Polypnoeic centers in infants, 43 



Porter's law, 114 

Porter, Wm. T., 114 

Precocity, early development of, 

119 

in the gouty child, 225 

physical basis of, 118 

Purin bodies, 78 

Putnam, Chas. P., 386, 388 



Rachitis, a cause of convulsions, 

138 
a cause of laryngismus 
stridulus, 158 

Rachitis, a cause of nervous 
symptoms, 102 

a cause of tetany, 168 

Recurrent coryza, 261 

a case of, 282 

etiology of, 261 

symptoms of, 262 

treatment of, 264 

Recurrent vomiting, 217 

acid intoxication in, 227 
cases of, 269-301 

character of vomited mat- 
ter in, 222 
complicating measles, 298 
convulsions in, 225, 281 
coryza in, 220, 286, 295 
diagnosis of, 226 
etiology of, 217 
medical treatment of, 232 
narcotism in, 224, 286, 300 
pathology of, 227 
prognosis of, 227 
recurrent coryza, toxic epi- 
lepsy, and migraine, a 
clinical study of, 268 
symptomatology of, 220 
urine in, 225 
Reflex centers, non-excitability 
of, in young infants, 31 



INDEX 



439 



Reilex excitation, a cause of 

asthma, 371 

a cause of chorea, 314 

eclampsia, 143 

enuresis, 181 

epilepsy, 245 

fever, 130 

headaches, 357 

insomnia, 390 

migraine, 197 

night-terrors, 382 

recurrent coryza, 261 

recurrent vomiting, 219 

tetany, 169 

Reflex irritations, common sights 

of, 105 

importance of, in producing 

nervous symptoms, 106 

may produce morphological 

changes in nerve cells, 107 

more important factor of 

disease in child than in 

adult, in 

Rheumatism, 310 

as a syndrome, 309 

a cause of chorea, 307 

nervous symptoms of, 90 

Richet, Chas., 42, 127 



Sachs, B., 239, 259 

Salicylic acid in the treatment 
of migraine, 211 

School life, a factor of neurotic 
disease, 116 

exaggerates hereditary ner- 
vous weaknesses, 118 
Scurvy, a cause of nervous 
symptoms, 102 
Sinkler, Wharton, 307 
Sleep, condition of the nervous 
system in, 378 
definition of, 378 



disorders of, 378, 380 

in the new-born, 280 

Sleep-talking, 394 

Sleep-walking, 393 

Snaw, I. M., 222, 282 

Somnambulism, 293 

treatment of, 394 

Sphincter muscles, incontinence 

of, 32 

muscular tone of, 31, 32 

Spinal irritability, no 

Starr, M. Allen, 307 

Sucking habit, treatment of, 

407, 408 

Suggestion, factor in producing 

hysteria, 338 

Syphilis, nervous symptoms of, 

92 

Temperature, not always an in- 
dication of fever process, 

33 

Tetany, 165 

differential diagnosis of, 173 

etiology and pathology of, 

165 

symptomatology of, 170 

treatment of, 173 

Thigh friction, 409 

diagnosis of, 412 

differs from masturbation, 

410 

etiology of, 409, 412 

prognosis of, 413 

spontaneous cure of, 412 

treatment of, 413 

Thumb-sucking, 407 

Thyroid intoxication, 60, 61 

Toxaemia, acute bacterial, 141 

acute intestinal, 131 

Toxic epilepsy, 240 

case of, 274 

treatment of, 259 



440 



INDEX 



Toxic chorea, 304 

Toxic headaches, 359 

Tuberculosis, a cause of chorea, 

313 
a cause of hysteria, 333 

a cause of nervous symp- 



toms, 



86 



Uric acid intoxication, role of 

liver in, 76 

Urination, nervous mechanism 

of, 177 

Urine in migraine, 201 

in recurrent vomiting, 225 

Urticaria, a cause of asthma, 

371 



Uraemia, a cause of convulsions, Vasomotor coryza, a prodrome 



143 
Uric acid bodies, excretion of, 

82 
formation of, 75 

theory of action of, 78 

toxicity, '78 



of recurrent vomiting, 220 

Vomiting, recurrent, 217 

Worms, a cause of pica, 423 
a cause of intestinal tox- 
aemia, 56 



IMPORTANT BOOKS 



Medical and Surgical Electricity, including x-Ray, 

Vibratory Therapeutics, Finsen Light and High Frequency Currents. By 
A. D. Rockwell, M.D. New and Enlarged Edition, Royal Octavo. 672 
pages. Illustrated. Half Morocco, $6.00 net. Cloth, $5.00 net. 

The Blues. (Nerve Exhaustion.) Causes and Cure. By Albert 
Abrams, M.D., 8vo. 240 pages. Illustrated. Cloth, $1.50 net. 

Childbed Nursing with Notes on Infant Feeding. By 

Charles Jewett, A.M., M.D., Sc. D., Professor of Obstetrics and Diseases 
of Women in the Long Island College Hospital, Brooklyn, N. Y. Fifth 
Edition. i2mo. 96 pages. Cloth, 80 cents net. 

Syphilis — A SYMPOSIUM. Contributions by Seventeen Distinguished 
Authorities. They give concisely the most recent and accurate inform -< tion on 
the various phases of this important subject. i2mo. 125 pp. Clo.,$I 00 net. 

Physical Diagnosis in Obstetrics, A Guide in Ante- 
partum, Partum and Post-Partum Examinations. By Edward A. Ayers, 
A.M., M.D., Professor of Obstetrics in the New York Polyclinic Medical 
School and Hospital ; Visiting Physician to the Mothers' and Babies' 
Hospital, New York. 8vo. 304 pages. Illustrated. Cloth, $2.00 net. 

Consumption, Pneumonia and Allied 

Diseases Of the LungS, Their Etiology, Pathology and 
Treatment, with a Chapter on Physical Diagonsis. By Thomas J. Mays, 
A.M. M.D., Professor of Diseases of the Chest in the Philadelphia Poly- 
clinic; Visiting Physician to Rush Hospital for Consumption. 8vo. 540 
pages. Illustrated. Cloth, $3.00 net. 

Sexual Debility in Man. By Frederic R. Sturgis, M.D. 
Formerly Clinical Protessor of Venereal Diseases, Medical Department, Uni- 
versity of the City of New York; Ex-Visiting Surgeon to the City Hospital, 
Blackwell's Island; one of the Authors of " A System of Legal Medicine," 
etc., etc. 8vo. 436 pages. Illustrated. Cloth, $3.00 net. 

Favorite Prescriptions of Distinguished 

Practitioners, with Notes on Treatment. Edited bv B.W. 
Palmer, M.D. Seventh Edition. 8vo. 248 pages. Cloth, $2.00 net. 

Nervous Exhaustion, (Neurasthenia), its 

Hygiene, Causes, Symptoms and Treatment. By George M. 

Beard, M.D., Formerly Lecturer on Nervous Diseases in the University of 
the City of New York, etc. Revised by A. D. Rockwell, M.D , late Pro- 
fessor of Electro-Therapeutics in the New York Post-Graduate Medical School 
and Hospital, etc. Fourth Edition. 8vo. 274 pages. Cloth, $2.00 net. 

The Sexual Instinct. Its Use and Dangers as Affect- 
ing Heredity and Morals. By James Foster Scott, B.A. (Yale), M D., 
CM. (Edinburgh); late Obstetrician to Columbia Hospital for Women, and 
Lying-in Asylum, Washington, D.C. 8vo. 436 pages. Cloth, $200 net. 

Treatment of Disease by Physical Methods. 

riassage. Electricity and Baths. By Thomas S. Dowse. MD. (Ab- 
erdeen), F.R.C.P. (Edinburgh^ 8vo. 420 pages. Illustrated. Cloth, $2.75. 

E. B. TREAT & CO., 24J-243 West 23d Street, New York 



a DISORDERS OF 

METABOLISM AND NUTRITION 

M L s | r Tp S hs°iy P™f. Dr. CARL von NOORDEN 

Physician-in-Chief to the City Hospital, Frankfort-on-Main 

Authorized American Edition Translat< l£ n E d ^ MrD D ^p e mL^ f L PH? A ARDMAN 

IT is due to the disorders of metabolism and nutrition that degenerative changes 
cut short the activities of so many men and women in middle life, — that, in 
these latter days, senility and death itself come prematurely to a very large pro- 
portion of mankind. Such disorders constitute the bane of our modern civilization. 
They have been in some measure also a reproach to the science and art of medicine, 
since until very recently they have not been studied with a thoroughness com- 
mensurate with their importance. 

I. OBESITY, THE INDICATIONS FOR REDUCTION 
CUR.ES. — In this volume the disease is considered in a manner which is at 
once scientific and practical; based upon exhaustive experiments and bedside 
observations carried on under the direction of the author. 

Cloth, 8vo, 60 pages, 50 cents. 

II. NEPHRITIS.— The author's handling of this subject is varied and 
original, and in various respects he has established for the treatment of the different 
forms of Bright's disease, rules founded upon a critical, scientific study of numerous 
cases instead of the familiar directions handed down from an earlier period. 

Cloth, 8vo, 112 pages, $1.00. 

III. COLITIS. — The author covers the complex subject of Membranous 
Catarrh of the Intestines (Colica Mucosa), in a manner which is well-nigh ex- 
haustive and also most convincing since he is able to report a remarkably large 
proportion of cures obtained by the method which he recommends. 

Cloth, 8vo, 64 pages, 50 cents. 

IV. THE ACID AUTOINTOXICATIONS.— These studies into 
the derangements of metabolism, which result in an overproduction of acid, 
concern the clinician very nearly. They are in a field which has been hitherto 
too little explored. Cloth, 8vo, 80 pages, 50 cents. 

V. SALINE THERAPY. — The author here decides many mooted ques- 
tions concerning the -nfluence of the sodium chloride waters on the digestion, as 
well as in gout, diabetes and other diseases of nutrition. 

Cloth, 8vo, 96 pages, 75 cents. 

VI. DRIVK RESTRICTION. (Thirst Cures)— A most instructive 
deliverance upon a subject of the highest practical importance. 

Cloth, 8vo, 90 pages, 75 cents. 

VII. DIABETES MELLITUS, A Series of Lectures delivered before 
the University and Bellevue Hospital Medical College, New York. Oct., 1905. 

Cloth, 8vo, 212 pages, $1.50. 

VIII. GOUT. In Press. 



E. B. TREAT & CO., Publishers, No4 **f&fi8g* Strect 



DISEASES 

OF THE 

Stomach and Intestines 

As well as the Allied and Resultant Conditions, with 
Modern Methods of Diagnosis and Treatment 

By BOARDMAN REED, M.D. 

THE AUTHOR has had large experience in this special field 
of medicine, supplemented by knowledge acquired during 
twenty years spent in a busy general practice among chronic 
invalids in Atlantic City, postgraduate work both in this country 
and abroad, and teaching in this special department, and is 
eminently qualified for the task he has so successfully completed. 

THE VOLUME covers so comprehensively the etiology, path- 
ology, symptomatology, diagnosis and treatment of the various 
diseases in question that it stands as the only thoroughly up-to- 
date single volume work on the diseases of the stomach and in- 
testines. The instruction is so plain and simple that every 
general practitioner, as well specialists in other lines, will find 
it a real help in the countless puzzling cases complicated with, or 
wholly dependent upon, derangements in the digestive system. 

SPECIAL FEATURES are ''The Gastrointestinal Clinic" in 
which the diagnosis and treatment of all known diseases of the 
tract are separately considered; a very complete " Symptomatic 
Guide to Diagnosis"; an account of the relations of gastroin- 
testinal diseases to numerous other affections, such as Neuras- 
thenia, Insomnia, Heart Disease, Kidney Disease, etc., and a 
comprehensive account of the diagnosis and treatment of 
Diseases of the Rectum and Anus contributed by Dr. Collier 
F. Martin, the well-known specialist. 



44 The author is clear and sound in his 
teachings, simplifies c editions as far as pos- 
sible, and gives a gocd practical working 
knowledge, such as he has gathered from a 
large experience in this special field. "—Medi- 
cal Record. 



" The need "of a modern treatise on this 
subject is evident from the limited literature 
and increasing demand for ttie same. Not 
only general practitioners, but also special- 
ists in other lines, will find it of great value." 
— A merican Medicine. 



Complete in One Large Octavo Volume; 1024 pages. 
Profusely Illustrated. Half Morocco, $6.00. Cloth, $5.00 

Sent Post or Express Paid on receipt of Price. Circulars upon request 

E. B. TREAT G CO., Publishers 
241*243 West Twenty-Third Street, Neto York 



MEDICAL AND SURGICAL 

USES OF 

ELECTRICITY 

INCLUDING 

X-Ray and Vibratory Therapeutics, the Finsen Light and 
High Frequency Currents 

BY 

A. D. ROCKWELL, A.M., M.D. 

Formerly Professor of Electro-Therapeutics in the N. Y. Post-Graduate Medical School and 
Hospital; Fellow of the New York Academy of Medicine ; Member of the Ameri- 
can Academy of Medicine ; Member of the New York Neurological 
Society: Formerly Electro-Therapeutist to the Woman's 
Hospital in the State of New York^ etc. 

Electricity in its relation to medical science, as well as to commerce, 
has made wonderful progress in recent years. The recognized pioneer 
work in America was the treatise on " The Medical and Surgical Uses of 
Electricity," by Beard and Rockwell, of which eight successive editions were 
issued. In 1896 the stereotype plates were destroyed and the work re- 
written by Dr. Rockwell, and issued from an entirely new set of plates. To 
keep abreast of the marvelous progress in this department of Medicine, a 
New Edition is again offered to the profession. The Roentgen X Ray in its 
relation to Diagnosis and Therapeutics has been entirely rewritten. Other 
additions include the subject of the Actinic Rays of light (Finsen's), High 
Frequency Currents and Vibratory Therapeutics. In the body of the book 
much that has served its purpose has been discarded and new and up-to- 
date material substituted. It is confidently believed that in its pages will 
be found a comprehensive and accurate survey of this fascinating and 
growing field of research. 



Medical Record, New York, says: "For 
twenty years and more the work of Beard and 
Rockwell has been the leading authority in 
this country on the subject which it treats. 
They were the pioneers in the field of elec- 
tro-therapeutics and enunciated ideas and 
methods which have stood the test of time. . 
. . The work plainly sets forth all the fun- 
damental principles of electricity, and in its 
relation to disease is clear in detail and can- 
not fail to greatly aid all who are interested 
in this department of medical science." 



Medical News, Philadelphia, says : "The 
methods of application for therapeutic pur- 
poses are given in detail and with such clear- 
ness that the general practitioner will find the 
book a useful and practical guide." 

Medical Journal, New York, says: "The 
book is much changed from the earlier edi- 
tions, being in accord with the advance in 
our knowledge of the applications of electri- 
city. . . . The work is valuable and will 
clear up many points which may be shadowy 
in the mind of the general practitioner." 



New, Revised and Enlarged Edition. 

Royal Octavo, 672 pages; Illustrated. 

Cloth, $5.00 net. Half Morocco, $6.00, net. 



E,. B. TREAT 6 CO., Publishers 

241-243 West 23d Street, New York 



OCT 37 1905 



V 



